Clinical Psychology for Trainees: Foundations of Science-Informed Practice

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Clinical Psychology for Trainees: Foundations of Science-Informed Practice

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Clinical Psychology for Trainees

This book describes the practice of clinical psychology with special emphasis on providing trainee therapists with the skills and strategies to achieve the core competencies required for a science-informed clinical practice. It will support the reader in making the transition from the lecture theatre to the consulting room. The approach incorporates a contemporary perspective on the multiple roles of clinical psychologists within a competitive health care market, where professional psychologists not only need to be accountable for their outcomes and efficiency in achieving them, but also need to be conscious of the social and political context in which psychology is practiced. Chapters are organized around the acquisition of key competencies and linked within an evidence-based, science-informed framework. Case studies, hand-outs, graphics and worksheets are employed to encourage the implementation of the skills described. This book should be read by all those enrolled in, or contemplating, postgraduate studies in clinical psychology. Andrew Page is Associate Professor in the School of Psychology, University of Western Australia, Co-director of the Robin Winkler Clinic and consultant to a private psychiatric service, Perth Clinic. Werner Stritzke is a Senior Lecturer in the School of Psychology, University of Western Australia and Co-director of the Robin Winkler Clinic.

Clinical Psychology for Trainees Foundations of Science-informed Practice

Andrew C. Page and

Werner G. K. Stritzke University of Western Australia


Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York Information on this title: © A. Page and W. Stritzke 2006 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2006 eBook (NetLibrary) ISBN-13 978-0-511-25071-2 ISBN-10 0-511-25071-1 eBook (NetLibrary) ISBN-13 ISBN-10

paperback 978-0-521-61540-2 paperback 0-521-61540-2

Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this publication to provide accurate and up-todate information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

To Gilbert and Ruth (AP) To Alfred and Ursula (WS)



page ix


A science-informed model of clinical psychology practice


Relating with clients



Assessing clients



Linking assessment to treatment: case formulation



Treating clients



Group treatment



Programme evaluation



Case management






Managing treatment non-compliance



Respecting the humanity of clients: cross-cultural and ethical aspects of practice



Working in rural and remote settings



Psychologists as health care providers


References Useful resources Index

252 277 281




Errors using inadequate data are much less than those using no data at all. Charles Babbage

All learning involves making errors. Knowing when errors occur and how to correct them is an important skill when developing the competencies needed to provide quality services as a clinical psychologist. From our clinical experience we have learned that a science-informed approach, while not perfect, is the best one available because, as Babbage said, the errors made are less than if we used no data at all. Good practice involves the integration of evidence-based treatment with treatment-based evidence, and is therefore inherently data-driven. Science can serve as an ally to the clinical psychology trainee by providing the foundation upon which the therapeutic relationship can flourish and produce beneficial outcomes. Although making errors when learning the complex tasks of a clinical psychologist may not be fun, the process of becoming a clinical psychologist deserves to be fun. The enjoyment comes from the excitement of developing new practical skills and gaining mastery in the effective delivery of therapeutic interventions. However, perhaps the most enjoyment of all comes from collaborating with another human being to bring about improvement in his or her well-being. Consequently, our aim in writing this book has been to provide a suitable companion on your journey to becoming a clinical psychologist. The journey and the destination should be enjoyable and, therefore, if we found it tedious to write about and irrelevant to the goal of becoming the best clinical psychologist, we left it out. This means that the book provides a practical guide to complement what you learn in your training. In developing the ideas and content in this book as well as the mode of presentation there are more people who should be acknowledged than is possible. Therefore, we will limit ourselves to thanking our students, who have allowed us the privilege of sharing the enjoyment as they begin the journey ix



of becoming a clinical psychologist, who have guided us to teach better, and who contributed to our School’s training programme by enthusiastically embracing the principles of science-informed practice while becoming actively involved in numerous programme evaluation projects and quality control exercises. Andrew Page and Werner Stritzke


A science-informed model of clinical psychology practice

Dineen (1998) argued in The Skeptic that psychotherapy is snake oil. She wrote that, While snake oil had no effective agent, it did have sufficient common alcohol to make people feel better until their ailments naturally went away. Similarly, psychotherapy has no effective agent, but people buy it, believe in it, and insist that it works because it makes them feel better about themselves for a while. This change, if it can be called that, may well be derived from nothing more than the expression of concern and caring, and not from specialized treatment worthy of payment (p. 54).

Skeptical criticisms such as this are not new to clinical psychology. When Eysenck (1952) reviewed the 24 available studies over half a century ago, he provocatively concluded that individuals in psychotherapy were no more likely to improve than those who did not receive treatment. Although the conclusion itself was questionable given the extant data (Lambert, 1976), the field responded assertively and effectively to these criticisms (e.g., Meltzoff & Kornreich, 1970). Perhaps the most effective response came from Smith et al. (1980). Using metaanalytic statistical techniques to review 475 studies, they provided quantitative support for the conclusion that psychotherapy was superior to both notreatment and placebo-control conditions (see also Andrews & Harvey, 1981; Prioleau et al., 1983). More recently, reviewers in the USA, UK and Australia have sought to take the next step and identify criteria for empirically supported treatments, thereby providing listings of treatments that are effective for particular disorders (e.g., Andrews et al., 1999; Chambless & Hollon, 1998; Nathan & Gorman, 2002; Roth & Fonagy, 2004; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). In parallel, other reviewers have collated evidence regarding the effective components of psychotherapy relationships (e.g., Norcross, 2000; Orlinsky et al., 1994, 2004). Together, these two lines of research provide a strong response to Eysenck’s criticism. While people continue to debate the relative merits and contributions of the


A science-informed model of clinical psychology practice

psychotherapy relationship and the specifics of particular therapies (e.g., Norcross, 2000; Wampold, 2001), the conclusion that psychotherapy is better than no treatment, and better than a supportive caring relationship alone, is strongly supported. Thus, Eysenck’s provocative criticisms spurred on a spirited and methodical response that allowed clinical psychology to clearly defend itself against general criticisms of ineffectiveness. In addition, the profession is able to identify, with increasing precision, the relational and specific therapeutic factors that mediate clinically meaningful change. Why was clinical psychology able to respond so effectively?

The scientist-practitioner model Arguably, the manner and effectiveness of the response owes a debt to the origins of Clinical Psychology within the scientific discipline of psychology and to an early and sustained commitment to a scientist-practitioner model (Eysenck, 1949, 1950; Raimy, 1950; Shakow et al., 1947; Thorne, 1947; see Hayes et al., 1999 and Pilgrim & Treacher, 1992 for historical reviews). From the establishment of the first clinical psychology clinic by Lightner Witmer, it was clear that science and practice were strategically interwoven. For instance Witmer (1907) wrote, The purpose of the clinical psychologist, as a contributor to science, is to discover the relation between cause and effect in applying the various pedagogical remedies to a child who is suffering from general or special retardation . . . For the methods of clinical psychology are necessarily invoked wherever the status of an individual mind is determined by observation and experiment, and pedagogical treatment applied to effect a change (p. 9).

Although there has been much written about the scientist-practitioner model, the broad principles are that clinical psychologists, as scientist-practitioners, should be consumers of research findings, evaluators of their own interventions and programmes, and producers of new research who report these findings to the professional and scientific communities (Hayes et al., 1999). The commitment to an ideal of combining research and practice has infused the profession of clinical psychology to such a degree (e.g., Borkovec, 2004; Martin, 1989; McFall, 1991) that the response to Eysenck’s skepticism (see also Peterson, 1968, 1976a, 1976b, 2004) was not an appeal to the authority of a psychotherapeutic guru, nor a rejection of its legitimacy followed by attempts to ignore it, but the profession produced and collated empirical data to refute the claim (Butler et al., 2006). Despite the success of the scientist-practitioner model in shaping clinical psychology as a discipline committed to empiricism and accountability, advocates of the model have not been blind to its failure to achieve the ideal


The aim of this book

(Hayes et al., 1999; Nathan, 2000). Shakow et al. (1947) aimed to train individuals who could not only be a scientist and a practitioner, but could blend both roles in a seamless persona. They sought to achieve this goal by giving an equal weighting in training programmes to research and practice. However, ensuring the mere presence of these two equally weighted components did not by default produce an integrated scientific practice and did not win the hearts and minds of many graduates. In the words of Garfield, ‘‘unfortunately, (psychologists in training) are not given an integrated model with which to identify, but are confronted instead by two apparently conflicting models  the scientific research model and the clinical practitioner model’’ (1966; p. 357; Peterson, 1991). More recently, there have been renewed efforts to provide a concrete instantiation of a scientific practice (Borkovec, 2004; Borkovec et al., 2001). Hayes and colleagues (1999) attributed the apparent lack of better sciencepractice integration to two factors: first, the ‘‘almost universally acknowledged inadequacies of traditional research methodology to address issues important to practice’’, and second, the ‘‘lack of a clear link between empiricism and professional success in the practice context’’ (p. 15). Our goal in the remainder of the book is not to address the first of these concerns (see Hayes et al., 1999; Neufeldt & Nelson, 1998; Seligman, 1996a), but to speak to the second. Our goal is to articulate ways that a scientific clinical psychology can be practiced.

The aim of this book Our aim is to assist the student of Clinical Psychology to contemplate a scientific practice and to develop a mental model of what a scientist-practitioner actually does to blend state-of-the-science expertise with quality patient care. Our goal is not to describe a model of clinical practice (e.g., Asay et al., 2002; Borkovec, 2004; Edwards, 1987), nor to outline a broad conceptual framework for a scientist-practitioner (see Beutler & Clarkin, 1990; Beutler & Harwood, 2000; Beutler et al., 2002; Fishman, 1999; Hoshmand & Polkinghorne, 1992; Nezu & Nezu, 1989; Scho¨n, 1983; Stricker, 2002; Stricker & Trierweiler, 1995; Trierweiler & Stricker, 1998; Yates, 1995), or even to portray a scientifically grounded professional psychology (Peterson, 1968, 1997), since each of these has been effectively presented elsewhere. Our aim is to consider each of the core competencies that a trainee clinical psychologist will acquire with the question in mind, ‘‘how would a scientist-practitioner think and act?’’ The value of the scientist-practitioner model as a sound basis for the professional identity and training of clinical psychologists lies in its emphasis on generalizable core competencies, rather than specific applications of these core competencies


A science-informed model of clinical psychology practice

to each and every client problem or service setting (Shapiro, 2002). Accordingly, we will first describe our conceptual model of the core elements of scienceinformed practice. Then, in the remainder of the book, we will illustrate how this model allows individual practitioners to provide value for money in a competitive health care market indelibly shaped by the forces of accountability and cost-containment (see also Fishman, 2000 and Woody et al., 2003).

A science-informed model of clinical psychology practice The starting place of any action in clinical psychology practice is the client and his or her problems. Therefore, the discussion of a science-informed model needs to begin with the client. In addition, the meeting of client and therapist involves a relationship, so that at its heart the interaction is relational. The beginning of the relationship involves the presentation of the client’s problems to the clinical psychologist. As shown in Figure 1.1, this information is conveyed to the clinician (depicted by the thin downward arrows) and some of it passes through the lens of the clinical psychologist. This lens comprises the theoretical and

Figure 1.1.

The process of linking client data to treatment decisions using case formulation


A science-informed model of clinical psychology practice

empirical literature as well as the clinical (and non-clinical) experience and training. This lens serves to focus the information about the client. Continuing with the lens metaphor, not all the information passes through the lens (indicated by some arrows missing the lens) because clinicians will be limited by the level of current psychological knowledge, their theoretical orientation, and the extent of their experience. As with all metaphors, the notion of a lens filtering client data is limited in that it does not capture the dynamic nature of the interaction between client and clinician. The client is not analogous to a light source passively emitting illumination, but a client actively engages in an interactive dialogue with the clinician so that the information elicited is influenced by the clinician’s responses, and the material the client proffers in turn influences how the clinician chooses to proceed. Thus, the interaction between client and clinician is a rich and dynamic dialogue, but while it has the potential to be a free-ranging and unconstrained discussion, the process has an error correcting mechanism in that the information is focused by the clinician and channelled into diagnosis and a case formulation. The case formulation, described later, provides direction to the decisions that a clinical psychologist makes about treatment (indicated by the dotted arrows), which are then implemented and their outcomes measured, monitored and evaluated. These processes involve feedback loops, so that information garnered at each stage feeds back to support or reject earlier hypotheses and decisions in a cycle of error correction. Finally, there are processes associated with the public accountability of clinical practice. The results of treatment are fed forward by the clinical psychologist to modify the theoretical and empirical bases of practice. In addition, the results will be fed back to inform the person’s clinical experience that will guide future clinical practice. Dissemination of evaluations of clinical practice outcomes serves not only to demonstrate that the practice is accountable, but also ensures the sustainability of clinical psychology. In the same way that logging forests without replanting new trees is unsustainable because it starves the timber industry of its raw material, if clinical psychology fails to replenish its resources (effective assessment and treatment), then it will be unsustainable. Other professions will step forward with potentially more efficient and effective alternatives to those which are presently available. Thus, we would agree with Miller (1969) that, ‘‘the secrets of our trade need not be reserved for highly trained specialists. Psychological facts should be passed out freely to all who need and can use them in a practical and usable form so that what we know can be applied by ordinary people’’ (pp. 10701). We can give psychology away in the sure knowledge that we are capable of generating new knowledge at least as fast as we can disseminate existing knowledge.


A science-informed model of clinical psychology practice

Stakeholders in the practice of clinical psychology In the previous section we outlined how the foundations of science-informed practice rest on the clinical psychologist assuming three interrelated roles. Clinical psychologists are consumers of research, in that they draw on the existing theoretical and empirical literature, they are evaluators of their own practice, and they are producers of new practice-based research and knowledge. However, the style of research and type of research product varies according to the stakeholder. Three classes of stakeholders can be identified (see Figure 1.2). The first stakeholder is the client (included in this category are the client’s family, friends and supporters). The second class of stakeholder is the clinician, including the professional’s immediate employment context (e.g., clinic, hospital, government department, etc.). The final class of stakeholder includes the broader society comprising individual members of society, government agencies, professional groups, academics, the private sector, etc. The type of research that each group will be interested in is displayed schematically in Figure 1.2. Clients have a legitimate interest in efficacy studies. Efficacy studies demonstrate in randomized controlled designs the superiority of a clinical procedure or set of procedures, presented in a replicable manner (e.g., using a treatment manual) over a control condition. The research has clearly defined inclusion and exclusion criteria, with an adequate sample size, and participants are evaluated by assessors blind to the experimental condition. Collating information across a group of efficacy studies permits identification of empirically supported treatments (e.g., Andrews et al., 1999; Chambless & Hollon, 1998; Nathan & Gorman, 2002; Roth & Fonagy, 2004; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). Clients may find this information useful in deciding which treatment has a good

Figure 1.2.

The relevance of three types of research activity in clinical psychology for three classes of stakeholder. The larger the area, the greater the relevance for a particular group


Stakeholders in the practice of clinical psychology

probability of success for carefully selected groups of individuals with problems like their own. Clients will have an even greater interest in the effectiveness of a given treatment and ongoing monitoring of their own condition. That is, effectiveness research evaluates treatments as they are usually practiced. In contrast to the treatment described in efficacy studies, clients who present for treatment may have multiple problems, may not meet all diagnostic criteria, and they will choose (rather than being randomly assigned) to receive a particular treatment whose duration is aimed to match their needs. The clinician may modify treatment based on a client’s response. Within this class of research one can include studies that examine the generalizability of efficacious treatments to real world settings (e.g., Peterson & Halstead, 1998), consumer surveys (e.g., Seligman 1995, 1996a, 1996b), as well as information on the outcomes of a specific clinic or clinician. Effectiveness can also be used broadly to refer to the measurement of change (e.g., pre- and post-treatment) within the client in question, the ongoing and idiographic monitoring of the client’s problems (see Hawkins et al., 2004; Howard et al., 1996; Lyons et al., 1996; Sperry et al., 1996 for examples), and issues concerning service delivery. Arguably, as the data become more personal, they become more relevant to the particular client and those who may be involved in the client’s care. Thus, in the left-hand box in Figure 1.2, proportionally more space is allocated to monitoring and effectiveness (light grey), than efficacy research (grey) to reflect the interests of an individual client. Moving to the far right-hand side of Figure 1.2, the interests of society are depicted. In contrast to the individual client, society will have a general interest in knowledge about the effectiveness of treatments but will have no particular interest in monitoring progress in the treatment of a particular individual. Thus, the relevance of monitoring and effectiveness studies (light grey) is less for society in general than the individual, indicated by the smaller proportion of the right-hand rectangle devoted to it. Society will have a greater interest in knowing the results of efficacy studies so that governments and investors can make rational planning and funding decisions, and services can be efficiently and effectively managed. Additionally, society takes an interest in a research agenda that may have little interest to individual clients, namely the research on the mechanisms and processes of disorders and treatment (dark grey). Included within this category of research endeavour are investigations of descriptive psychopathology and the etiological mechanisms that initially cause or maintain a set of client problems as well as those mechanisms involved in client change (e.g., O’Donohue & Krasner, 1995). The category also includes research into the process of psychotherapy (e.g., Norcross, 2000); that is, research on the relationship variables critical to client improvement.


A science-informed model of clinical psychology practice

Standing between the clients on the one hand and society on the other, is the clinical psychologist. Clinical psychologists share the interests of both the client (in the monitoring and measurement of each client’s particular problems and the delivery of the most efficacious treatment) and society (in understanding the fundamental mechanisms involved in each problem a client may present with and knowing which treatments are efficacious for a particular problem, and the degree to which these treatments translate into practice). For example, for the present authors, when we manage our clinic’s smoking cessation and anxiety disorder programmes (Andrews et al., 2003; Page, 2002a) we not only want to know that the programmes are empirically supported, that they are effective outside the centres where they were tested on carefully selected samples, but we need to be able to demonstrate that the outcomes of our clinicians running our programmes are comparable to those in the published literature. Likewise, while a single case study may not always be publishable, it provides an excellent way for individual practitioners to demonstrate to themselves and to a client the degree of improvement (Fishman, 2000). Drawing together the themes discussed (and portrayed in Figures 1.1 and 1.2), the scientific practice of clinical psychology exists in a social network that ripples outward from the individual client, with a research agenda that becomes more general, theoretical and generalizable as the conceptual distance from the client increases. Thus, there is probably not one single science-informed model of clinical psychology, but an array of ways that science informs practice and vice versa. The knowledge generated by large-scale efficacy studies (e.g., Elkin et al., 1989) exists alongside the knowledge generated by an individual clinician tracking the Subjective Units of Discomfort (SUD) of a phobic progressing through an exposure hierarchy. Both can appropriately be considered the products of a scientific practice of clinical psychology. Acknowledgement of diversity in the type of research product across different stakeholders is not to imply that there are no boundaries to a scientific clinical psychology, just that it is broader than it is often characterized. Presenting evidence to stakeholders

It is worth noting that specification of the different stakeholders helps to clarify what information needs to be presented to which groups and by whom. Individual clients will be interested in feedback about how they have performed on psychological tests relative to appropriate normative samples and about the rate and extent of progress, both referenced against their pre-treatment scores and relevant norms (see Woody et al., 2003: Chapter 5). Further, the results of therapy may be communicated to other stakeholders in ward rounds, clinic meetings, training workshops and other clinical settings (cf. Haynes et al., 1987).


Stakeholders in the practice of clinical psychology

In contrast to the local presentation of individual client data, professional societies and funding bodies will seek information about the most cost-effective ways to treat specific disorders of all clients who present for treatment. They will require reliable answers, based on a body of research studies comprising good internal and external validity that point to answers that can be generalized to particular populations. Thus, an important skill for clinical psychologists is not only to be able to produce evidence, but to know how to generate and present research outcomes relevant to the target stakeholder. One example of the targeted presentation of research evidence is the way that clinical psychology is responding to the increasing industrialization of health care. Health care costs began to rise dramatically during the 1980s and it became clear that both the private and public sectors needed to be more assertive in the management of health funds. Employee Assistance Programmes (EAPs) were one of the first responses, offering corporations targeted services of early identification and minimal, time-limited interventions, followed, if necessary, by appropriate referral. In the USA, managed (health) care organizations evolved with the development of Health Maintenance Organizations (HMOs; where individuals or companies contract an organization to provide all health services), Preferred Provider Organizations (PPOs; who reimburse a panel of providers on a fee-for-service basis, typically with some form of co-payment), and Individual Practice Association (IPAs; in which providers organize themselves to contract directly with companies to provide health services). Although the particular structure of health care varies markedly across different countries, all Western nations face the same problems of increasing costs of health care (compounded by a growing aged population) and share the same need of third-party payers (i.e., insurance companies and governments who pay the health bills) to rein in health care costs. Increasing costs have focused attention more than ever upon efficient and effective health care and thus, the need for clinical psychologists to be able to demonstrate that their assessment and treatment processes are not only effective, but they can be targeted, delivered in a timely manner, and offered in a definable and reproducible manner. Thus, in the past the rationale for a scientific-informed practice was promoted within the discipline by professional organizations (e.g., the American Psychological Association, British Psychological Society) and foresighted individuals (e.g., Thorne, 1947), but in recent times the rationale has become increasingly externally motivated, in the form of third-party payers who are demanding cost-effective health care. Whereas in the past the scientist-practitioner model could be seen as a luxury representing an ideal worthy of pursuit, in the present era of accountability it is a necessity ideally suited to demonstrate the value that can be returned for every health care dollar invested in clinical psychology services. As consumers


A science-informed model of clinical psychology practice

seek to purchase quality services at cheaper prices, there will be a market edge to those who are able to demonstrate that their products are both effective and economical. In sum, science-informed clinical psychology does not have a single product to market, but it produces many different outputs relevant to diverse audiences. Clients will be interested in their personal well-being, whereas society will be interested in the broader issues of descriptive psychopathology, etiological models of disorders, treatment processes and outcomes, as well as efficient and effective health care. The individual clinical psychologist requires the skills to collect and present data relevant to particular stakeholders. Not all clinical psychologists are employed in the same capacity and the stakeholders each person deals with are different, and therefore it is better to conceptualize the implementation of a science-informed model of clinical practice as not being epitomized by a particular instantiation, but as a strategic commitment to a scientific approach at the core of clinical practice. Priority of strategy over procedure is essential because the evidence base will always be incomplete. The core competencies of a scientist-practitioner are most needed when the evidence is equivocal or lacking (Shapiro, 2002). Thus, clinical psychologists have no need for ‘‘snake oil’’; science is a far better elixir and the active agent of psychotherapy. In the remaining chapters we outline ways that a person with a commitment to the application of science to clinical practice might approach the many tasks clinical psychologists engage in. The first of these activities will be the difficult task of developing a strong therapeutic relationship.


Relating with clients

Imagine sitting face to face with your first client. What is the best thing to do or say? What if you open your mouth and say the wrong thing? This is an appropriately daunting image because you want to do the best for your client and the stakes are high. Minimally, a therapist must aim to do no harm, but how is one to exert a positive influence? One common response among students is to seek technical guidance in the form of a treatment manual. There are published lists of empirically-supported treatments (e.g., Nathan & Gorman, 2002) that identify the relevant treatment manuals and it makes sense to find the manual that matches the client’s problem and to begin therapy. Furthermore, this seems reasonable because the practice is scientific, in that you can base your clinical decisions on the empirical literature. Other students respond to the challenge of exerting a positive influence upon clients by seeking to focus on the therapeutic relationship. Once again, this is not an unscientific strategy since there is a substantial literature identifying aspects of the therapeutic process beneficial to outcomes (e.g., Beutler et al., 2004; Orlinsky et al., 2004). This approach has a long history with Frank (1973) suggesting that psychotherapy is an encounter between a demoralized client and a therapist aiming to energize the client. Frank placed less emphasis on what was done in therapy, and more emphasis upon how it was done; specifically, he emphasized the therapist’s ability to mobilize a client’s motivation and hope. Thus, there are sound reasons for identifying an empirically-supported treatment best suited to a client, but there are also good reasons for fostering the therapeutic relationship. This still leaves one with the apparent dilemma, what is the best thing to do or say? However, the dilemma is easily resolved if one understands that the two approaches are not mutually exclusive, but complement each other.


Relating with clients

Borkovec (2004) spoke of this issue as he outlined his vision of an integrated science and clinical practice. In answer to the question, ‘‘What is the empirical evidence for what you do with a client?’’, he commented that, Certainly research on relevant empirically supported treatments (ESTs) is part of this review process, but it goes further. The professional commitment of clinical psychologists is to be knowledgeable about, and guided by, the empirical foundation of everything they do during the therapy hour, and the psychological literature contains far more information relevant to this potential foundation than merely (though importantly) therapy outcome studies documenting the efficacy of specific protocol manuals (p. 212; italics added).

The empirically-based choice of the best treatment programme is one component of a scientific practice of clinical psychology, but it is not the whole of it. To use a culinary metaphor, scientific practice is not a garnish sprinkled onto clinical psychology, but it is like salt that once added to food permeates the whole dish. The scientific practice of clinical psychology and the use of empirically-supported treatments do not abdicate a clinician from the responsibility of fostering a therapeutic relationship in the best interest of the client. We will later consider some components of empirically-supported treatments, but first we will review empirically-supported components of the therapeutic relationship. The separation is not intended to imply that these are alternative options of conducting psychotherapy. Both aspects are integral parts of a strategic approach to provide an empirical foundation for everything that happens in a therapy hour. Empirical foundations of the therapeutic relationship The promulgation of treatment manuals could give the false impression that the therapist behaviour exerts little influence over and above the specific ingredients of the manualized therapy. A series of studies by Miller and colleagues highlights how this conception would be false (Miller et al., 1980; Miller & Baca, 1983). They found that a treatment programme for problem drinking was equally effective when delivered by therapists or in a self-help format. However, when they further explored the data, they found considerable variability within the therapist-administered treatment programme. Specifically, two-thirds of the variance in drinking outcomes at six months post-treatment was predicted by the degree of therapist empathy. Even two years after the completion of therapy, still one quarter of the variance in drinking outcomes was predicted by therapist empathy. Thus, there were some therapists who administered a standard treatment programme with outcomes that far exceeded those achieved with self-help, but there were other therapists whose clients would have been better off if they had read the book by themselves. Therefore, scientist-practitioners will need to


Empirical foundations of the therapeutic relationship Table 2.1. Size of the relationship between therapeutic process variables and outcome.

Process variables

Effect size (r)

Client variables Client suitability for the treatment offered Client collaborative versus dependent or controlling Client co-operation versus resistance Client contribution to therapeutic bond Client affirmation (respect and liking) of therapist Client openness versus defensiveness Client conversational engagement (verbal activity) Client experiencing (i.e., articulation of felt meaning) Client focusing on life problems Client expressiveness (linked with therapist empathic responses)

0.5 0.5 0.5 0.5 0.5 0.4 0.4 0.4 0.4 0.4

Therapist variables Therapist affirmation (acceptance, warmth, positive regard) of client Therapist skillfulness Therapist contribution to bond Therapist focusing on client problems Therapist empathic understanding Therapist engagement versus detachment Therapist credibility (sureness versus unsureness)

0.5 0.4 0.4 0.4 0.4 0.3 0.3

Variables characterizing the relationship Therapeutic bond/cohesion Reciprocal affirmation between client and therapist Goal consensus/expectational clarity

0.5 0.4 0.3

identify and cultivate those therapeutic behaviours that reliably relate to positive client outcomes (e.g., Miller & Rollnick, 2002). One way to identify empirically-supported therapeutic behaviours is to determine which behaviours that occur during treatment are positively correlated with therapeutic outcomes. Orlinsky and colleagues (Orlinsky et al., 1994, 2004) have reviewed the substantial literature relevant to this question. We will use their work to illustrate how a clinical practice can be informed by this literature. Using their review (Orlinsky et al., 1994) we identified behaviours that were not therapy-specific, for which there was a sizable empirical basis (i.e., at least 10 studies) with consistently positive findings (i.e., at least 50% of listed studies). We then extracted the mean effect sizes (converted to r) and organized the results under subheadings (see Table 2.1).


Relating with clients

From the simplified data presented in Table 2.1 it is clear that process variables can be divided into the three categories, namely those related to the client, the therapist and the relationship. Bearing in mind the caveat that the actions of a client and therapist affect each other reciprocally, it is possible to draw a number of lessons from the table. First, the quality of the therapeutic relationship is strongly related to outcome and both client and therapist behaviours are involved. Thus, it is critical to consider what activities enhance the therapeutic bond. Second, clients possess a variety of qualities that are positively associated with outcome. While there will be individual differences in these qualities, it behoves the therapist to maximize the extent to which these behaviours are exhibited during treatment. For instance, client conversational engagement is positively correlated with outcome and although clients will vary in terms of their levels of verbal activity, the therapist should be mindful of strategies to maximize client verbal activity. Third, a novice therapist may take some comfort from the observation that although therapist credibility is related to outcome, the size of the effect is weaker than many others. That is, even if you feel unsure when you are seeing a client, remember that this variable is not among the largest predictors of therapeutic outcome. Drawing together the main points from Table 2.1, it is apparent that certain client behaviours as well as specific therapist behaviours should be maximized to enhance outcome. Outcomes will be enhanced when the therapist creates an environment in which the client is able to discuss their problems collaboratively in an open and easy manner. The therapist will be working hard to maximize the therapeutic bond, by showing empathic affirmation (acceptance, warmth, positive regard) of the client. In a nutshell, the therapist will work hard to develop the therapeutic alliance.

Building a therapeutic alliance Broadly speaking, the therapeutic alliance involves three components (Bordin, 1979). First, the client and therapist agree on therapeutic goals. Second, the therapeutic alliance involves the assignment of a task or set of tasks for the client, which can occur within the therapy session or between sessions. The final component is the development of a therapeutic bond. As Ackerman and Hilensroth (2003) noted, despite much research focusing on the relationship between the therapeutic alliance and outcome (e.g., Orlinsky et al., 1994, 2004), much less research has addressed the particular behaviours of the therapist that foster and strengthen the alliance. Based on a review of the existing literature,


Building a therapeutic alliance

they identified a set of therapist attributes and techniques that are positively related to a strong therapeutic alliance. Their work suggests that in terms of personal qualities, a good alliance is associated with therapists who present with a warm and friendly manner, and who appear confident and experienced. Therapists with a good therapeutic alliance will be interested in and respectful towards their clients, and they will relate with honesty, trustworthiness and openness. During therapy they will remain alert and flexible. In terms of providing a safe environment for clients to discuss their issues, therapists will be supportive and use reflective listening skills, affirm the clients’ experiences, and demonstrate an empathic understanding of each client’s situation. Therapists will attend to the clients’ experiences and facilitate the expression of affect, to enable a deep exploration of concerns. In terms of the practice of therapy, clinicians with a positive alliance provide accurate interpretations of client’s behaviours, are active in treatment, and draw attention to past therapeutic successes (Ackerman & Hilsenroth, 2003). Drawing together the themes evident from the preceding reviews of therapy processes and the therapeutic alliance, a number of general conclusions can be drawn about the conduct of a therapy session. First, in terms of the therapist, it is important to be warm, empathic and genuine. Second, the client needs to be actively engaged in therapy, with a good understanding of what is occurring. Third, the relationship between the client and therapist needs to be collaborative with a good rapport. We will now illustrate the specific behaviours that can strengthen the alliance by describing how they may be appropriate at different points in an initial session with a client. Relating with a client to build an alliance

To begin a session it is useful to begin with a polite introduction, taking an effort to be warm and friendly. Therefore, make sure that you make eye contact as you say the client’s name and permit time for the small talk that often follows an introduction (e.g., a discussion of parking difficulties or problems finding the clinic). However, the small talk must not detract from attention to the problem, so to convey a genuine interest in the client you need to shift focus swiftly to the client’s main concerns. Thus, invite the client to sit down with chairs arranged so that you sit side on, but still facing the client, at a comfortable distance. Before asking the client to describe their concerns, it is important to discuss issues of confidentiality (see Chapters 8 and 10). Briefly, there are two aspects to this. On the one hand, you want to make it explicit that material raised remains confidential. On the other hand, confidentiality is not absolute and there will be occasions when you may be legally or ethically bound to inform a third party. It is prudent to draw the client’s attention to these circumstances


Relating with clients

(e.g., when there is an explicit threat to harm the self or another specified person, when a child is in danger, or when subpoenaed by a court of law) verbally or in written documentation. Although it may seem a little awkward to raise these issues, it is easier to raise them at this point and it also allows clients a few moments to settle themselves. Once the preliminaries are over, it is time to ask the client to introduce the problem. Since you are trying to be respectful and affirming, it is useful to let the client provide this introduction. On some occasions you will have referral information or prior case notes and therefore you may want to begin by indicating to the client that you would ‘‘like to hear it from you first’’. In asking about the client’s difficulties you are aiming to create a sense of openness. One way to do this is to begin by asking, ‘‘What seems to be the problem?’’ or ‘‘What brought you along today?’’ In so doing do not impose a structure, but let the client raise the issues as they would like to (but see Chapter 13 for circumstances when it is important to impose structure right away; for example, in many medical settings, time constraints often require rapid assessment skills, and a purposeful structure is essential for eliciting as much information as possible in the limited time available). Ask questions, but permit the client to define their problems. Sometimes you will have prior information and it can be helpful to mention this. For example, ‘‘You mentioned on the phone that you were having difficulty with ‘depressed mood’, could you tell me about it?’’ On occasions clients are reticent at the outset of therapy and it may be useful to acknowledge some of the discomfort, perhaps by saying, ‘‘People are often concerned about seeking professional help, but I’m glad you came to see me. It is the first step in doing something about your difficulties.’’ In asking a client questions, the form of questions can be closed or open. Closed questions can be answered in a few words or even with a simple yes or no (e.g., ‘‘Do you live with your family?’’). They are useful for focusing an interview and obtaining specific information, but used to excess they constrain the client and place the burden of directing the session upon the therapist. Open questions are those that take many words to answer and in so doing, encourage the client to provide the maximum amount of information (e.g., ‘‘What is your relationship with your family like?’’). Thus, open questions are preferable as ways to begin an initial interview with a client, but relatively more closed questions may be used to begin a session later on in therapy (e.g., ‘‘Last week we talked about managing your tension while asserting yourself. How did you go with that?’’). As the client is talking you need to reflect upon how you are coming across to the client. First, be aware of your eye contact. Make sure that you look at the client. Although you will normally look away more often when you are


Building a therapeutic alliance

speaking than when you are listening and eye contact is rarely a continuous stare, you need to be able to watch the client for behavioural signs relevant to their problems (e.g., breaks in eye contact, shifting in their seat). In addition, eye gaze is an important implicit cue in communication used to signal turn taking (i.e., a speaker will restore eye contact to signal that a communication is complete) or to seek confirmation (e.g., a speaker will look to a listener when expecting a response to their communication). It is also important to be aware of cultural differences in eye contact (e.g., Australian Aboriginal people tend to avoid contact when discussing serious topics). One trap for the novice therapist to avoid is excessive note taking. The client is not a topic to be studied, but a person with whom you are relating. Therefore, jot down an occasional aid to memory rather than a transcript of the conversation. Building a warm and friendly relationship is more important to the therapeutic alliance than a comprehensive record of the session. Second, in terms of body language scan both the client and yourself. Ensure that your proximity is comfortable to the client, so that if they move their chair forward or backward, do not adjust yours to a distance negating the client’s move. Watch for changes in body posture that indicate discomfort or greater assurance. Also be alert for discrepancies between the client’s body language and their verbal tone and content. For example, the client who folds her arms while saying that she is quite comfortable with her boss’s decision. Likewise, ensure that your body posture does not communicate impatience (e.g., pen tapping), boredom (e.g., doodling), defensiveness (e.g., arms crossed), and discomfort (e.g., breaking eye contact). Your aim is to convey honest acceptance while supportively affirming the client. If you feel unsure how best to sit, mirroring the client’s behaviour can be a good start or leading the client by modelling a relaxed and open manner (e.g., feet firmly on the floor, arms on your legs with palms open). Third, your voice needs to convey friendly interest. Therefore, watch for signs of emotional tone in your voice and ensure that it matches any emotional content. Likewise, pay attention to the client’s emotional tone. In addition to tracking the vocal tone, track the verbal content. Align your conversation with the client’s interest and signal any transitions (e.g., ‘‘I was wondering if we could switch from the problems you are presently having with your drinking and go back to when it all began, so that I can get a clearer idea of where it all came from. Is this OK with you?’’). Transitions signal a change, but it is also useful to include a brief summary of the material covered most recently in the session to indicate that you have been listening to the client. The way that you respond to the client will influence the course of the interview, so track the verbal tone and content of your responses. For instance, consider how the tone of the


Relating with clients

interview and the content of the client’s response would vary if you responded to the client saying, ‘‘I’ve just lost my job’’ with (a) ‘‘that was very careless of you’’, (b) ‘‘how did that happen?’’, or (c) ‘‘how do you feel about losing your job?’’ Another way to track the client’s verbal content is to identify important words. Statements that begin with ‘‘I’’ can often be relevant because they are important to a client and the use of the personal pronoun communicates the personal significance. Clients will also emphasize certain words to highlight key issues. For instance, confusion or ambivalence about impulsive behaviour may be indicated by emphasis in a sentence such as, ‘‘WHY do I keep drinking too much and getting together with the wrong sort of guys?’’ The questions that you ask will help the client to elaborate upon their responses. For example, in an initial interview you could ask open questions to facilitate greater discussion of a topic by asking, ‘‘Could you tell me more about that?’’ or ‘‘How did you feel when that happened?’’ Sometimes you will need to get a client to be more specific or concrete and at such times you could ask, ‘‘Could you give me a specific example?’’ or ‘‘Tell me about a typical drinking session’’. The form of a question will also influence the type of answer. What questions, often lead to factual answers, therefore they are the easiest to answer. How questions initiate a discussion of processes and an account of a sequence of events. Why questions bring about a discussion of possible reasons. One problem with why questions is that even though they give you an indication of the client’s perceptions of causation, they can put individuals on the defensive and may produce discomfort if they imply blame. Further, Nisbett and Wilson (1977) mount a convincing case that humans do not have introspective access into the causal cognitive processes despite being happy to elaborate on what they believe to be the correct answer. This is perhaps also one reason why a frequent response by clients to a why question is ‘‘I don’t know’’. Why -questions are difficult to answer on the spot. Nonetheless, awareness of a client’s perception of the cause of their problems (independent of its validity) is useful information when presenting to a client a problem formulation. An alternative to asking direct why questions is to indirectly pave the way toward some causal insight by beginning with a what question. For example, an answer to the question ‘‘Why are you upset with your husband’s decision?’’ requires considerable cognitive processing entailing deliberation and judgement. In contrast, the question ‘‘What is it about your husband’s decision that upsets you?’’ prompts the client to simply describe and list all the things that come to mind that are upsetting to her. It is far easier for the client to look at a list of concrete exemplars, and then arrive at an overall judgment why she was upset, than to ponder that question in the abstract via internal processes. Thus, what questions are often better than why questions


Building a therapeutic alliance

in eliciting answers about the reasons for a client’s behaviours, thoughts or feelings. Finally, could questions (e.g., ‘‘Could you tell me what your husband does that makes you mad?’’) tend to be maximally open-ended and generate many options for the client (including a refusal to answer, which can be beneficial). However, as you ask questions, remember the goal of therapy is not just to elicit information, but to facilitate a communication. Therefore, track the client’s responses to your style of interaction. If your client looks confused, check that you have not been using multiple questions (e.g., ‘‘I wonder if you could tell me when the difficulties with your wife began, first her jealousy and then her drinking, but also tell me how you felt about each of them and how each of your children reacted to the whole situation?’’). If your client looks uncomfortable, check that you are not asking an excessive number of overly probing or closed questions. In a therapy context, the clinician exerts a degree of influence over the interview that is not present in social contexts, such that clients feel obliged to answer each question. Therefore, reflect on each question and ask yourself if you need to know the information. Although the material elicited in a session is confidential, you do not wish to explore a client’s private life any more than you need to. Also, if the client is reticent about answering your questions, consider if you have been using statements framed as questions. For instance, you might say, ‘‘Don’t you think it would have been more helpful if you had studied harder?’’ which is really a judgement about the client’s effort rather than a helpful therapeutic question. In our experience, one word to watch out for in this respect is so. Often a question or statement that begins with so is one that is about to tell the client what you think. For instance, you might say, ‘‘So you’ve been feeling pretty bad lately’’. These comments are much better re-phrased as genuine questions (e.g., ‘‘Could you tell me how you’ve been feeling lately?’’). Fourth, non-attention and silence are potentially useful therapist responses. If a client repeatedly brings up the same topic, you may feel the need to shift attention elsewhere. The danger with this strategy is that clients may keep returning to topics when they do not believe you have understood what they are saying or how distressed they are. We will discuss reflective listening in more detail later, but if you are sure that you have heard the message and it is time for a change in topic it is sometimes useful to say, ‘‘I hear how distressed you are’’ while maintaining eye contact with the client. Wait until you get a clear sense that your message has been heard by the client before moving on. The novice therapist is sometimes worried about silence, believing that the job of the therapist is to fill the therapy hour with words. Notice in our review of the process variables that were related to outcome, the verbal output of the client, but not of the therapist was consistently related to outcome. Therefore, do not


Relating with clients

worry about silence. Sometimes saying nothing is the best support you can give. Sometimes you cannot think of what to say because there is nothing to say. Sometimes you need time to think about the best response. Either way, a receptive silence can be a useful therapeutic tool. Encouraging, restating and paraphrasing

So far we have considered the style of questioning and behaving. Although these techniques are important, the goal of a session is to both give and receive information. The information the client is providing will be both verbal and non-verbal. Some information will be communicated explicitly by the client. Other information will be communicated without the client’s awareness or will need to be inferred by the therapist. Receiving all the client’s messages, decoding them correctly, and conveying to the client that you have accurately heard and understood the rich and complex tapestry of words, emotions and behaviours is at the heart of empathic communication. Three strategies that assist the therapist to communicate that client messages have been received are encouraging, restating and paraphrasing. Encouraging typically involves behaviours such as head nods, open gestures, positive facial expressions and verbal utterances (e.g., ‘‘U-huh’’). Each of these therapist responses seeks to convey an encouragement to continue with a particular line of style of responding. These encouragers need to be used judiciously, since too few leave the therapist looking wooden and too many can be annoying. Remember, the responses are intended to encourage elaboration on particular points, so make sure that you use them when you wish to reinforce a particular utterance. Thus, one trap to avoid is saying ‘‘yes’’ before a client has finished a sentence or idea. Therapists can also provide encouragement by repeating key words from a client’s response. For instance, if a client said, ‘‘It happened again. I walked into the office, it went quiet, and I felt that everyone was looking at me. Suddenly I felt that rush of anxiety and started to blush’’ you might respond, ‘‘Everyone was looking at you?’’ or ‘‘you blushed?’’ Each response encourages the client to elaborate on a particular facet of the experience and the clinician will opt for a particular line of response depending on the overall agenda. The preceding responses would lead the session towards a discussion of the office workers’ perceptions on the one hand or the client’s physiological response on the other. Later in therapy a clinician might wish to explore recurring patterns and may wish to draw attention to the repetition by responding, ‘‘It happened again?’’ Other encouragers may be more focused. For instance, you might ask questions to establish the generality of a behaviour (e.g., ‘‘How often do you drink each day?’’), situational influences (e.g., ‘‘Where do you drink?’’),


Building a therapeutic alliance

onset (e.g., ‘‘When did it all begin?’’), or course (e.g., ‘‘Has it been the same all the time?’’). Paraphrasing is a deceptively simple skill. The aim is to distill the client’s explicit and implicit messages into a single utterance. The verbal and non-verbal cues, the key ideas that have been spoken and inferred concepts, are concisely summarized. Thus, the key skill in paraphrasing is not speaking, but listening. Begin by paying attention to everything the client is communicating and take time to reflect on the explicit and implicit messages. Consider any themes or important features, evaluate the discrepancies between verbal and non-verbal communications, and formulate a response. Although we will now turn to ways that a summary can be expressed, we cannot emphasize enough the extent to which the key to a successful summary is the thought that occurs before you open your mouth. Providing a good summary can also be facilitated by collecting relevant information. Asking the client how they react to their problems and how others respond can provide you with key elements to include in a summary. A summary often begins with a stem, such as ‘‘It looks to me . . .’’ or ‘‘What I’m hearing is . . .’’ or ‘‘Putting these ideas together . . .’’. The summary brings together the main points of the issue from a client perspective. To convey clients’ perspectives, try to use their language. For instance, if clients have used the terms sadness and grief to describe their experiences, use their words rather than another such as depression. Try to clearly express the main elements of the problem. Often clients will be confused and ambivalent so the therapist can assist by highlighting key themes or drawing together seemingly unrelated symptoms into a coherent picture. Finally, after presenting a clear, succinct, and meaningful summary, request explicit feedback to check your understanding. You might ask, ‘‘Am I hearing you right?’’ In addition, check that your coverage has been sufficient. We prefer questions such as ‘‘What have I missed out?’’ rather than ‘‘Have I missed anything out?’’ because the former presumes incompleteness and inaccuracies and therefore implicitly encourages correction. Putting together these three skills of encouraging, restating and paraphrasing, imagine how you would respond to a client who said, ‘‘I’m really concerned about my teenage daughter. She used to talk to me and now she has become sullen and withdrawn, so we don’t talk. I’m so worried that she’s getting into something bad. She’s got all these new friends and she won’t tell me what they get up to. I don’t know what to say, but if she’s been using drugs then she can just leave home as far as I’m concerned!’’ An encourager might be to respond, ‘‘You don’t talk?’’ A restatement might be, ‘‘You are terribly concerned about your daughter.’’ Finally, a paraphrase might be, ‘‘I’m hearing a few themes emerge in what you say. One theme is that you seem concerned; concerned about the loss of communication with your


Relating with clients

daughter and concerned about the possibility of harm, so much so that you’d consider asking her to leave. Another theme seems to be one of loss; you describe a sense of loss of communication, closeness and influence. Have I heard you right?’’ In the paraphrase, some elements are reflections back of what the client said, but others are inferences based on the client’s comments. That is, the client did not discuss her feelings about a loss of influence and control over her daughter as she becomes more independent. However, the therapist knows this is a common issue between parents and teenage children, so speculated that this unspoken theme was present, and therefore presented it as a hypothesis. It is wise to check that a paraphrase is correct, but essential to do so when an inference or speculative interpretation is being presented. These three communication skills are useful steps in developing an empathic understanding between you and your client. However, empathy goes deeper than communication. Empathy is the ability to see the world from the perspective of another person and communicate this understanding. Behaviourally, it is possible to define verbal and non-verbal actions and attending skills that are associated with empathy, but at its heart empathy is a relational construct. It involves putting yourself into another person’s shoes so that you can share a deeper relationship (Egan, 2002). The deep relationship involves positive regard. Positive regard involves selectively attending to the positive aspects of a client’s communication. It stems from a humanistic worldview that people are inherently moving forwards and growing in a positive way (i.e., self actualizing). Highlighting these positive aspects identifies positive assets a client can build upon and conveys a sense of warmth and acceptance. Empathic communication also conveys respect and warmth. Clients may not have told others about the issues that they raise in therapy and thus, it is important to convey respect for the client. Show that you know that they are doing their best to deal with their issues. Transmit appreciation for the person’s worth as a human being and communicate warmth by smiling or using facial expressions conveying empathic concern when responding to a client’s emotions. The empathic therapist also needs to demonstrate congruence (having a minimal discrepancy between their perceived and actual self), genuineness and authenticity. Possession of these attributes ensures congruence between verbal and non-verbal behaviours which ultimately facilitates communication with clients. Clients are the focus of any session and therefore the therapist’s issues must not clutter the therapy process. Therapists who are not fully accepting of their clients may exhibit incongruence between their verbal and non-verbal behaviours which clients may pick up on. Like reflecting the verbal content of a communication, reflecting an emotion begins with a sentence stem followed by a feeling label. The emotional word



or phrase aims to use the minimum number of concepts to reflect the affect in the correct tense. For example, match your tense to that used by the client, so that if a client says, ‘‘I felt down’’ it would be better to use the past tense, than to say, ‘‘Your mood seems low’’. Once again, conclude with a check to ensure that your reflection of feeling is accurate. One facet of a session that is easy to omit is an assessment of the client’s skills, strengths, and resources. It is a common trap to fall into because clients want to discuss their problems. However, clients are first and foremost people, who also happen to have some problems. Therefore, spend time explicitly considering clients’ coping mechanisms and supports. You might ask, ‘‘With whom do you talk most often?’’ and then discuss what they enjoy talking about. Evaluate if they use other people for distraction, dependence, encouragement and motivation, or clarification. You can also ask the client about interests, social activities and religious/spiritual practices. When coming to the end of a session summarize the issues covered and draw the themes together. Typically clients will have identified a set of concerns, thus you could say, ‘‘Have I got it right, it seems that the main issues for you are . . . let us try to rank them into a stepladder of concerns beginning with the least problematic and stepping up to the more concerning’’. This hierarchy can help set an agenda and identify a tentative treatment plan. Also check that nothing has been omitted by saying, ‘‘You have talked about your checking and the intrusive thoughts as well as your depressed mood. Are there any issues we haven’t talked about that you’d like to discuss?’’ or ‘‘Is there anything else you would like to tell me?’’ Finally, at the end of a session, conclude with a clear statement about what is going to happen next. This may involve psychological testing or scheduling a referral or another appointment. The goal is to leave clients with a sense of closure and clarity about the next step.

Troubleshooting One of the attributes of a strong alliance is flexibility. Therefore, as a clinician it is important to be able to bend with clients. A planned session structure may need to be put on hold or re-organized depending on what clients raise. The uncertainty created may instil a degree of discomfort which the therapist needs to learn to tolerate in order to be responsive. Having said this, there are common issues clients raise that it is good to have some considered answers. First, clients often ask, ‘‘Do you think you can help me?’’ Therapists must avoid being overly optimistic, especially if clients raise the issue at the outset of an initial session. If you have not collected sufficient information to answer the


Relating with clients

question, then indicate that you would prefer to return to it at the end of the session. If you say this, then make sure you do return to the issue (perhaps putting a reminder at the end of your notes). On the other hand, if you have a clear idea about the probable treatment response and a client asks ‘‘Can you cure me?’’, then emphasize that you will be working with the client to help them to learn strategies to better manage troubling situations, relationships, behaviours and emotions. Sometimes describing a stress-diathesis model is helpful in communicating to the client their role in dealing with their problem. For instance, a sunscreen metaphor can be of assistance, where you explain that a person with fair skin will burn more easily in the sun. They might not be able to change their tendency to burn, but they can learn to put sun-screen on to cope better with the potentially damaging rays of the sun. Second, some clients (especially those with anxiety) may worry that they are going crazy. Silence can be damning at this point, as clients will watch you for signs of hesitation and interpret these as indications of your true beliefs. Therefore, respond quickly and convincingly. Typically, people (with anxiety) are worried that they have schizophrenia and comparing and contrasting their symptoms with those of a psychotic disorder can be helpful. Third, clients will often cry during a session. Ensure that tissues are on hand (and it is wise to routinely check they are within a client’s easy reach before the session begins). In addition, use non-verbal cues to convey support and sympathy. Lean forward in your chair (but do not touch the client) and allow silence. Do not rush in and provide reassurance, but allow the client’s crying to reach a natural conclusion. Be satisfied with silence until the client uses verbal or non-verbal cues to signal they are seeking a response. Clients often end a period of crying by apologizing or saying ‘‘that was silly’’. Rather than engaging with these sentiments, it is more useful to redirect attention to the trigger and its response by saying something like, ‘‘It seems this situation upsets you a great deal’’. Fourth, clients can be agitated in the session. When you notice increasing agitation, it is most helpful to break off from the current line of inquiry and focus on it directly by saying, ‘‘You seem uncomfortable today, what is wrong?’’ Fifth, although novice therapists often worry they will not be able to fill the therapy hour (and hence over-prepare), a more common problem is a talkative client. It is particularly a problem for novice therapists because if you have worried that you will not fill the session, or are concerned that you might say the wrong thing, a talkative client is a seeming godsend since you do not have to say another word. However, silence is not always the best response. The client may need your guidance, so start to use closed questions. You also may need to be more intrusive and interrupt the client to impose some order.



For instance, you might say, ‘‘You have raised many issues, which one is the most important?’’ Sixth, clients can ask you for your advice (e.g., ‘‘what do you think I should do?’’) or invite you to take sides (e.g., ‘‘You agree with me don’t you? No-one should have to put up with that sort of behaviour’’.) In each of these situations, it is helpful to draw attention to the collaborative nature of the session. As a therapist you are there to work with the client, but at the end of the day, they are the ones who must live their lives. Therefore, you might respond, ‘‘I don’t want to talk about what I would do, because we are talking about the problems you are facing. However, I am going to work with you to see if we can find some solutions to these problems’’. Seventh, clients (and therapists) may wander off topic and it becomes necessary to refocus the interview. Sometimes is it useful to say, ‘‘I’d like to get back to your main concerns’’ or ‘‘I’m wondering if it might be more productive to focus on your current situation for the time being’’. Clients may also depart from the therapist’s schedule by wanting to move too rapidly into treatment. This is understandable, since clients seek resolution of their problems, but it may be necessary to cover other material in the session first. The clinician might say, ‘‘I need to know more about your current problems before we can work out a plan of action’’. The client may also want to focus on a domain (e.g., childhood relationships) before fully explaining the problem. Thus, the therapist might say, ‘‘I would like to know more about your upbringing, but first I need to understand more about your current difficulties. Is this OK with you?’’ Finally, clients can ask you for information that you deem to be personal and off limits. The therapeutic relationship is not the same relationship that exists between friends, acquaintances, or even doctor and patient. Rather, it is friendly, in that it is truthful, honest, caring and attentive. Thus, there is empathy, but also a degree of disengagement. Clients come to discuss their problems; you are not there to discuss yours. Clients are there to discuss their lives; you are not there to elaborate on yours. That being said, it can be discourteous and unhelpful to refuse to respond to any requests. Clients may reasonably desire to have some idea of the person they are sharing intimate details with. Therefore, consider before therapy begins, the nature and extent of material you are willing to divulge. For instance, clients can ask if you have had a problem like theirs. Therefore, consider if you have, how you will respond and equally, if you have not, how you will respond. Additionally, clients may ask about your personal life (e.g., ‘‘do you have children?’’) since this may establish your credibility to them. How will you respond comfortably in a genuine and truthful way and what will be most beneficial to the client? Refusing to answer questions point blank can disrupt the relationship and evasive and disingenuous answers are often


Relating with clients

annoying to clients. Further, in some settings (e.g., rural and remote locations) the issue of therapist confidentiality is a moot point. Since you live in the community in which you work and socialize with the people who are potential clients, the boundaries need to be made explicit with clients (see Chapter 12). Even therapists in urban areas need to reflect on the possibility of meeting a client in a non-therapy setting. For example, the authors have met their clients in the changing room of a gym, at parties, at airports, and even on a remote wilderness track! Therefore, consider how you are going to respond when you meet your clients outside of therapy and if this is likely, then it may be wise to raise it explicitly.

Summary In conclusion, a science-informed clinical psychologist needs to be cognizant of the empirical literature relevant to the therapeutic relationship. Empirically supported treatments may include specific components that bring about change in the client’s behaviour, but the therapeutic relationship is a way of bringing the client into contact with the therapy. Deciding upon a treatment requires careful consideration of many client-related factors and making this decision requires careful assessment of the client as a person and their presenting problems. Assessing clients is the topic to which we now turn.


Assessing clients

Picture yourself conducting a clinical interview. A 32-year-old married woman has presented to the service where you are working with difficulties getting to sleep and so you have prepared by reading about insomnia. You open the interview by asking the client to elaborate on her problem. She describes lying in bed, unable to sleep because concerns and worries spin around her mind. In addition to the symptoms you expected, the client tells you that she is overly irritable during the day, has extreme difficulty concentrating, is chronically indecisive, and feels immense fatigue. Suddenly, the seemingly simple problem of insomnia has expanded as the client describes other problems that could be part of the sleep difficulties, but could represent another problem altogether. As a clinician you are faced with a number of dilemmas: . Are the problems related in any way? If so, which problem do you treat first? . Are the problems manifestations of one underlying cause or multiple causes? . What treatment is best for which problem or constellation of problems? Clinical psychologists tackle these dilemmas with every new client. From Figure 3.1 it is apparent that the assessment process involves an objective psychometric assessment, the gathering of relevant background information during an intake interview, and an examination of the client’s mental state based on observations made during the interview. Together, these data permit a description of the particular profile of symptoms, along with a formulation of the predisposing, precipitating and maintaining factors of symptom presentation. Diagnostic manuals represent the distillation of clinical experience and research into a format that identifies which problems tend to group into meaningful clusters. These clusters can assist therapists to plan potentially effective treatments because as scientist-practitioners they are then able to refer to and use the psychological literature that bears on the relevant diagnoses. In this chapter we will first consider current diagnostic practices and their limitations, as well as structured ways to conduct diagnostic interviews and a mental state


Assessing clients

Figure 3.1.

The complementary processes of testing, interviewing and examining mental state as precursors to diagnosis, case formulation and treatment planning

examination. However, before considering diagnostic systems, it is necessary to define mental disorder. What is a mental disorder? In its Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10, WHO, 1992), the World Health Organization does not define a mental disorder. Rather, the authors note in the section on classification of mental and behavioural disorders that although they use the term disorder (in preference to disease and illness), it is ‘‘not an exact term, but is used here to imply the existing of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and interference with personal functions’’ (WHO, 1992; p. 5). In contrast, the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (Text Revision of the Fourth Revision; DSM-IV-TR; APA, 2000) does attempt to define a mental disorder. A mental disorder is a ‘‘clinically significant


Diagnostic systems

behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom’’ (p. xxi). In addition, the authors note that the definition does not include an expectable and culturally sanctioned response to a particular event (e.g., bereavement). Further, they note that the ‘‘behavioural, psychological, or biological dysfunction’’ must lie within the individual, thereby excluding behaviour that is deviant (e.g., political, religious, or sexual) or conflicts with society (see Blashfield, 1998; Rounsaville et al., 2002).

Current diagnostic practices The many different instances of psychopathology present a complex array of phenomena to be organized. Clinicians need to organize the various manifestations of psychopathology for a number of reasons. First, it is necessary to have an agreed nomenclature so that mental health professionals can share a common language. Second, a common language is needed so that information about particular psychopathologies can be retrieved. Third, classification is a fundamental human activity that is necessary to organize the world within which we live. Presently, there are two main diagnostic systems, the American Psychiatric Association’s DSM-IV-TR (APA, 2000) and the World Health Organization’s ICD-10 (1992, 1993). Both of these diagnostic systems classify disorders (rather than clients; Spitzer & Williams, 1987) and thereby assist clinicians as they try to plan treatment in a systematic, rational and scientific way.

Diagnostic systems: the diagnostic and statistical manual of mental disorders (DSM) and the international classification of diseases (ICD) The DSM-IV

The opening chapter of the DSM-IV-TR (APA, 2000) provides a comprehensive discussion of how to use the manual. The manual itself describes a method for assigning a Multiaxial Assessment. That is, each client is assessed on five axes. Each domain of assessment provides information potentially useful in treatment planning and the prediction of outcomes. The axes are: 1. Clinical disorders; other conditions that may be a focus of clinical attention 2. Personality disorders; mental retardation 3. General medical conditions


Assessing clients

4. Psychosocial and environmental problems 5. Global assessment of functioning Axis I: clinical disorders

Axis I contains the psychological disorders that may be the reason for treatment. The major groups of disorders to be reported on Axis I are: (i) Disorders usually first diagnosed in infancy, childhood, or adolescence (excluding Mental retardation), (ii) Delirium, dementia, and amnestic and other cognitive disorders, (iii) Mental disorders due to a general medical condition, (iv) Substance-related disorders, (v) Schizophrenia and other psychotic disorders, (vi) Mood disorders, (vii) Anxiety disorders, (viii) Somatoform disorders, (ix) Factitious disorders, (x) Dissociative disorders, (xi) Sexual and gender identity disorders, (xii) Eating disorders, (xiii) Sleep disorders, (xiv) Impulse-control disorders not elsewhere classified, (xv) Adjustment disorders, and (xvi) Other conditions that may be a focus of clinical attention. Each section in the DSM-IV-TR follows a similar format. The title of the disorder is followed by a verbal description of the diagnostic features. This section provides clarification of the diagnostic criteria and includes examples. It complements the stark criteria listed later, in that it provides a rich verbal picture of the disorder, thereby giving the clinical psychologist the context within which the symptoms occur and the manner in which the disorder may present. Developing a sense of the flavour of each disorder, over and above a list of the criteria, is important and in addition to the DSM material, case studies are a useful complementary source of information. Some particularly good examples include Meyer (2003), Sattler et al. (1998), Oltmans et al. (1995) and Spitzer et al. (2001). Following this section, the DSM-IV-TR provides information on the subtypes of the disorder, associated features, specific cultural, age and gender features, the prevalence, course, familial patterns, and differential diagnosis (i.e., distinguishing from similar or related disorders). Finally, the specific diagnostic criteria for the disorder are listed. By way of illustration, a Major Depressive Episode is characterized by a period of at least two weeks with depressed mood or a loss of interest in pleasure. In addition to one or both of these symptoms, to meet diagnostic criteria, a client must also report or exhibit a total of five of the following: significant weight or appetite change, insomnia/hypersomnia, psychomotor agitation or retardation, fatigue/energy loss, feelings of worthlessness or excessive/inappropriate guilt, decreased thinking ability or concentration, or indecision, recurrent thoughts of death, suicidal ideation without plan, or suicide attempt or plan. Subsequent criteria require the clinician to rule out other possible diagnoses (e.g., a general medical condition or bereavement) and


Diagnostic systems

to ensure that the distress or impairment in social, occupational, or other important areas of functioning is clinically significant. The criteria for clinical significance rely upon clinical judgement and may use information from friends, family and other third parties. In the case of depression, once the judgement has been made that a client meets criteria for a Major Depressive Episode, the clinician must judge which disorder the client meets criteria for. This distinction is made because an episode of depression can occur within many distinguishable affective disorders. For example, one possibility is Major Depressive Disorder, Recurrent in which the client will need to have had two or more Major Depressive Episodes and no mania. The clinician is then asked to specify the severity and other features of the disorder. The severity of a disorder is coded as mild if few, or no, symptoms in excess of those required to make the diagnosis are present (in this case five), and symptoms produce minor impairment in social or occupational functioning. It is coded as severe if many symptoms in excess of those needed to make a diagnosis are present, and severity is moderate if the number of symptoms falls between mild and severe categories. For instance, a client with repeated episodes of depression would receive a diagnosis of ‘‘F33.0 Major Depressive Disorder, Recurrent, mild’’. The clinician also needs to consider specifiers that describe the course of the disorder (e.g., chronic), its recurrence and the features that are present. By way of example, one set of features is melancholia, in which the depression feels distinctively different from bereavement, is worse in the morning, involves early morning wakening, and so on. Axis II: personality disorders and mental retardation

The second axis of the DSM codes the (a) Personality disorders and (b) Mental retardation. These disorders are coded separately to ensure that clinicians consider these diagnostic categories in addition to the Axis I disorders, since having a Personality disorder or Mental retardation does not exclude a person from having an Axis I disorder. The presentation of disorders in Axis II follows a similar pattern to Axis I. Axis III: general medical conditions

The third axis of DSM allows the clinician to indicate current general medical conditions potentially relevant to understanding or treating Axis I or II mental disorders. For example, a woman’s severe episode of depression was precipitated by surgery for a prolapsed uterus, with the subsequent doctor’s orders not to lift anything weighing as much as a cooking pot. Consequently, her husband and children had taken over most household chores. The client was despondent about her perceived inability to make any meaningful contribution to the family


Assessing clients

activities. Clearly, noting this medical condition in the diagnostic impression helps to understand the context of the depressive episode, and the absence of a prior history of depression and other risk factors indicates a good prognosis. Axis IV: psychosocial and environmental problems

The DSM permits the clinician to code significant psychosocial and environmental problems that have occurred in the preceding year, in part acknowledging that such factors may moderate the treatment and prognosis of mental disorders. Environmental problems include negative life events, environmental difficulties or deficiencies. Psychosocial problems include relationship difficulties and the associated interpersonal stress, as well as insufficient social support or personal resources. Both psychosocial and environmental problems may be causally related to the onset of problems, but can also be a consequence of mental health problems. However, if the psychosocial or environmental problem is the primary reason for treatment it will also be coded on Axis I as an ‘‘Other conditions that may be a focus of clinical attention’’. These problems can include problems with (i) the primary support group, (ii) social environment, (iii) education, (iv) occupation, (v) housing, (vi) finances, (vii) access to health care, and (viii) interaction with the legal system/crime. Consider once more the previous example of the woman who plunged into a deep depression following her forced idle state due to a medical condition preventing her from lifting heavy objects. The situation was exacerbated by her also losing her part-time job as a carer working with disabled adults, where heavy lifting of patients was part of her daily job routine. Thus, noting the concomitant job loss on Axis IV provides insight into the pervasiveness of her recent role transition from active provider for the family to being a burden to her family. Axis V: global assessment of functioning (GAF)

The final axis in DSM provides the clinician’s assessment of the individual’s overall level of functioning. The GAF ranges from low levels of functioning characterized by potential harm to self or others, through moderately impaired daily functioning due to the impact of serious symptoms, to superior functioning. This information is useful in planning treatment and measuring its impact, and in predicting outcome. A GAF is important to measure for a variety of reasons because functional impairment is not the same construct as subjective distress, even though impairment and distress are frequently confounded in the concept of problem severity. Separating the constructs is important because impairment is negatively related to improvement during treatment (McClellan et al., 1983), clients with a high degree of impairment appear to improve to


Diagnostic systems

a greater degree with longer and more intensive treatment (Shapiro et al., 1994), and impairment is a predictor of relapse (e.g., Brown & Barlow, 1995). The ICD-10

Despite the popularity of the DSM in many countries, the official coding system for international comparisons is the International Classification of Diseases, Tenth Revision (ICD-10; WHO, 1992). The ICD-10 does not use a multiaxial system of diagnosis, although there is discussion of a triaxial system in which clinical diagnoses are on Axis I, disabilities on Axis II, and contextual factors on Axis III. The ICD diagnoses are presented in two volumes. The first volume includes the clinical descriptions and the diagnostic guidelines. Like the DSMIV-TR, the ICD-10 organizes the disorders into various categories which are (i) Organic, including symptomatic, mental disorders (e.g., dementia in Alzheimer’s disease), (ii) Mental and behavioural disorders due to psychoactive substance use (e.g., harmful use of alcohol), (iii) Schizophrenia, schizotypal and delusional disorders, (iv) Mood (affective) disorders, (v) Neurotic, stress-related and somatoform disorders (e.g., generalized anxiety disorder), (vi) Behavioural syndromes associated with physiological disturbances and physical factors (e.g., eating disorders), (vii) Disorders of adult personality and behaviour (e.g., trans-sexualism), (viii) Mental retardation, (ix) Disorders of psychological development (e.g., childhood autism), and (x) Behavioral and emotional disorders with onset usually occurring in childhood and adolescence (e.g., conduct disorders). Each disorder under each of these broad categories is listed, beginning with a description of the main clinical and important associated features, followed by diagnostic guidelines. In contrast to the DSM-IV-TR, the ICD-10 does not list explicit criteria for each diagnosis. That is, there are no verbal descriptions that indicate the quantity and balance of symptoms required before a diagnosis can be made. Therefore, the ICD provides a degree of flexibility that is less evident in the DSM system, because sometimes clinical decisions need to be made ‘‘before the clinical picture is entirely clear or information is complete’’ (WHO, 1992; p. 1). The companion volume within the ICD-10 (WHO, 1993) lists the research diagnostic criteria, and the format is much more similar to the DSM in that particular criteria are specified for each disorder. By way of comparison and contrast, the ICD identifies three varieties of a depressive episode, ranging from mild to severe. In contrast to the DSM, where a client with a mild diagnosis must first meet the two diagnostic criteria for a Major Depressive Episode plus at least five additional criteria, a mild depressive episode in ICD would require only two symptoms from a list including depressed mood, loss of pleasure, reduced energy and fatigue, and two symptoms


Assessing clients

from tiredness, reduced concentration and attention, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, bleak views of the future, ideas or acts of self-harm or suicide, disturbed sleep, and diminished appetite. The diagnostic specifiers used in DSM-IV-TR are incorporated into the ICD by asking the clinician to code the particular category. Therefore, a client with repeated mild episodes of depression may receive a diagnosis of ‘‘F33.0 Recurrent depressive disorder, current episode mild’’. Note that the diagnostic codes are equivalent, yet the quantity and type of diagnostic criteria are not identical (see Rounsaville et al., 2002). Both diagnostic systems acknowledge the need for cultural sensitivity when assigning diagnoses. This will be achieved by explicitly considering the client’s ethnic or cultural reference groups and possible cultural explanations of a client’s symptoms. For instance, the mode of expression may vary across cultures (e.g., greater somatic presentations of mood disorders in some cultures), and so too can the meaning of symptoms and causal models used by clients to explain their symptoms. Although some disorders appear culture-specific, the more usual situation facing the clinician requires sensitivity to the ways in which cultural and other social factors influence the presentation and impact of a disorder, as well as the way they are communicated to and understood by the clinician.

Conducting a diagnostic interview Independent of the diagnostic system used, one product of an initial interview (when possible) is a diagnosis. Eliciting symptom information is a necessary, but not sufficient component of a diagnostic interview. In addition to determining which symptoms a client possesses and which he or she does not, the clinician aims to develop a clear picture of the client, the problem(s), and the personal, social and environmental context within which these issues occur. The exact nature of the interview will be tailored to the client and to the problem, but a useful conceptual structure for an interview is outlined below. The way that you meet the client will frame the dialogue. Since your aim is to assist a client discuss potentially sensitive issues, a good rapport is required. Therefore, communicate a sense of goodwill by being courteous. As discussed in Chapter 2, questioning at the outset of the interview should be open and designed to help the client talk while the clinician listens. One possible obstacle to an open dialogue is note taking. This occurs if the clinician focuses excessively on the notes at the expense of the client. Spend time building rapport with the client and respond to what the client says in a way that communicates that you


Conducting a diagnostic interview

understand not only what the client has said, but how the client felt. Therefore, try to take sufficient but brief notes and in a manner that does not interfere with the flow of the interview. Usually, a diagnostic interview will quickly move to the presenting problem(s) and the aim will be to identify the problem that the client has brought to therapy. While there may be times when tact and sensitivity dictate a more gradual introduction, clients typically arrive at a consultation prepared to tell their story. Thus, it may be helpful to encourage the client to phrase the problem in their own words. For instance, you may ask, ‘‘I wonder if you could tell me what brought you here today?’’ As the client begins to respond to this question, ensure that you model good listening behaviour. Respond with verbal and non-verbal indications that you have heard and understood not only the content of the speech, but also the broader emotional and social context that the person is in. For example, a clinician might interview a client with Generalized Anxiety Disorder (GAD) in the following manner. Therapist Your referral suggests that you are having trouble with sleeping. Could you tell me a bit about the troubles you’ve been having? Client Well, I just can’t get off to sleep at night because these worrying thoughts keep popping into my head. They just go around and around, so that I can’t fall asleep. I’m now so tired that I feel that if I could just get a good night’s sleep everything will be OK again. Therapist These worries seem to be having a huge impact on you. Client They are. In fact, they seem to be the main problem. Therapist What sort of things do you worry about? Client About anything and everything. I worry about my children’s health, I worry about not having enough money, I worry about the house burning down, I worry about work . . . I even worry that I worry about worrying. Therapist Can you tell me about this ‘worry about worrying’? Client I feel I need to worry. If I don’t, then I worry that something terrible will happen. Like when my children go out at night, I’m never sure that they’ll be safe, but if I worry then I feel that things are better because I’ve done everything I can. Therapist Do these worries occur at times other than when you are trying to go to sleep? Client Yes, they happen all the time. Right now I’m worrying that you might not be able to help me because I’m not being clear enough. This has been going on for years now and I don’t know if I have a problem or if it’s just the way I am.


Assessing clients

Therapist When people worry a lot for a long time, there can be effects in the rest of their life. Have you noticed any impact of the worry? Client As well as the sleep, I notice that I get really tense. The muscles around my neck tighten up so much that I’m in pain. Therapist That must be exhausting as well as painful. Client You’re right. I am so tired from all the worry and tension, but I still don’t seem to be able to sleep it doesn’t make sense. Therapist We’ll talk about trying to make sense of your experience a little later, but for the time being I’d like to continue to get a clear idea in my head of the problems you are facing. When other people experience excessive worry and uncontrollable tension, they sometimes notice that they are more irritable or feel on edge and tense. Have you felt like this? Client Always on edge and . . . erm . . . what was the other thing? Therapist Irritable? Client Yes, often irritable at home, but never at work. Therapist How about difficulties with concentration? Client I don’t seem to have trouble concentrating, just that I concentrate on my worries. Therapist When you are trying to concentrate on your work, do your worries break into that concentration? Client Yes, but its not that I can’t concentrate. I concentrate on the wrong thing. A number of issues are evident in the preceding conversation. First, if you consult the DSM-IV-TR criteria for Generalized Anxiety Disorder you can see that the clinician is asking the client about symptoms relevant to the disorder. At the beginning, the clinician begins with open questions, but towards the end of the section the questioning becomes closed and more focused as the clinician moves to check that material was omitted because the symptoms are indeed absent, rather than the client just failing to report material even though the symptoms are present. Second, you will see that the client becomes confused when multiple symptoms are included in a single question. Try to avoid questions that contain multiple issues and requests. Third, you will see that the client and clinician do not have a shared understanding of the word concentration. For the client, concentration refers more to the cognitive process, whereas the clinician is referring to the ability to focus on a particular thought. In the preceding conversation, the client took the initiative in clarifying the issue, but had the client not done this, the clinician could have been more explicit in the questions. Finally, at the end of this section, the clinician would be in


Conducting a diagnostic interview

a position to speculate that the client may be suffering from GAD. Further questioning would clarify this but it would appear that the client has been experiencing excessive worry for more days than not for some years about a number of events (DSM-IV-TR Criterion A). There is difficulty controlling the worry (Criterion B), the worry is associated with feeling keyed up or on edge, easily fatigued, irritability, muscle tension, and sleep disturbance (Criterion C), and there is clinically significant distress and impairment (Criterion E). Criterion D requires the clinician to determine that the worries are not confined to the features of another Axis I disorder. Thus, the clinician will need not only to explore GAD, but it will be necessary to entertain the possibility that the symptoms are a manifestation of other disorders (e.g., primary insomnia, major depression and substance abuse) and hence a differential diagnosis is required to determine the best label to describe the client’s problems. It is also possible that the client exhibits comorbidity, and hence two disorders (e.g., GAD and depression) are present simultaneously. Further interviewing is required and for each disorder, the DSM-IV-TR provides details about how to make a differential diagnosis. After the client has begun to describe the problem, the clinician is confronted with a choice of direction. On the one hand, the clinician could choose to remain with a discussion of the presenting problem and elicit personal and historical information later. The advantages of this strategy are that the interview continues to flow naturally and the client keeps relating the details of the presenting problem. However, the disadvantage is that the clinician does not have a good picture of the client as a person, the social and historical background to the problems, a sense of other psychological problems, and so on. Instead, the clinician could signal a change of direction by saying, ‘‘Thank you. You have given me an idea of the difficulties that you are having. I would like to pursue them in more detail, but before we talk about these difficulties I was wondering if I could get some idea about you as a person?’’ The interviewer could then proceed to ask questions about the social and personal background. The advantages of this strategy are that the psychological problems are then unveiled in the context of the whole person. The main disadvantages are that the clinician may not know what aspects of the personal history are relevant until the problem is explicated and the interview may need to be cut short because insufficient time remained to discuss the client’s difficulties before the session ended. Assuming that the clinician has decided in this instance to remain with a discussion of the presenting problem, this could be signalled with a comment such as, ‘‘I wonder if we could discuss the difficulty you have been mentioning in some detail. When did you first notice that something was not right?’’ This will direct the client to discuss the evolution of the problem; acknowledging the fact


Assessing clients

that psychological difficulties exist in a dynamically evolving system. However, within the complexity, the clinician will be focused on trying to highlight the key milestones in the problem development. This history will lead the client towards the present, at which time it will be possible to get a clearer description of the difficulties and any associated behaviours. As a mental checklist, the clinician will be aiming to identify (i) what the problem is, (ii) when it occurs, (iii) where it happens, (iv) how frequently the problem takes place, (v) with whom these difficulties arise, (vi) how distressing and (vii) impairing the problem is. In collecting this information, the clinician will also identify distal factors associated with the problem. These will be identifiable from a discussion of the environment, context and lifestyle present when the problem began, other predisposing and triggering factors, the consequences of the problem’s onset, the way the problem has changed over time and factors associated with these changes (both increases and decreases in severity and frequency). The interview will evolve from a historical discussion to consideration of the problem in its current form. The clinician might ask, ‘‘Could you please tell me about a typical day or occurrence of the problem?’’ and then explore some of the maintaining factors. The clinician will also ask about the variability in the problem and factors associated with the fluctuations (i.e., moderating variables). As far as the diagnostic aspect of an interview is concerned, the clinician will elicit a comprehensive description of the problem and its various manifestations. Clients may often focus on one aspect of the problem because it is salient to them, but remember to explicitly consider the behaviour and actions, consciously available thoughts and other cognitive processes, as well as physiological changes. The clinician also needs to ask about the frequency, intensity, topography (typical and unusual patterns), duration and temporal sequence of symptoms. In addition, the consequences of any behaviour need to be thoroughly assessed (see Chapter 4). After the clinician has a good sense of the presenting problem, its present manifestation, and its history, the interview can expand to provide a more complete picture of the person. The clinician might say, ‘‘You have given me a good idea of the problems you are struggling with, but I don’t think I have got a good idea about you as a person. Could you tell me something about you, apart from these difficulties?’’ The aim of this process is to be able to put yourself in the client’s shoes and imagine what it must be like to experience the life the client has had. Therefore, it may be relevant to ask about family history (details of parents, other significant figures, brothers and sisters, as well as the childhood environment of family, school and peers), a personal history (birth date and any significant issues, general adjustment in childhood, lifelong traits or behavioural patterns and tendencies, and significant life events), schooling (duration and


Adapting diagnostic interviews for different client groups

significant events), work history and present duties, relationships (current status, history and problems), leisure activities, living arrangements, social relationships, prior significant accidents, diseases and mental health problems, and personality (and particularly any changes). An important aspect of a diagnostic interview is to identify the coping resources that a client can bring to bear in seeking to overcome their problems. Therefore, enquire about coping resources and other personal strengths the individual possesses. Within this context, motivation for change is a critical dimension (see Miller & Rollnick, 2002 for an excellent discussion). The clinician will not only attempt to identify the motivations intrinsic to the person, but identify any extrinsic motivators that are present or have been successful in the past. The clinician can also try to identify the stage of change that the client is in. That is, Prochaska et al. (1995; Prochaska & Norcross, 1998) have suggested that clients move through a series of stages. In the first instance, individuals are precontemplators  they have their problem, but have not yet got to the point of desiring to modify their behaviour. As a person begins to notice the impairment or becomes increasingly concerned about the distress being triggered, they move into the contemplation phase, in which they are considering the pros and cons of dealing with the problem. From contemplation, a client will move into preparation and action, after which time they will either relapse into any of the preceding stages or continue to manage the problem successfully. At the end of the interview, summarize and synthesize the material covered. Often it is useful to present this summary in a provisional manner by saying, ‘‘I will try to draw together some of the themes we have been discussing. If I miss something out or if I get a point wrong, please let me know’’. It is also prudent to ask the client if there are any problems or issues which you have not asked them about or for which there has not been time to discuss. This increases confidence that the main problems have been covered and also provides an opportunity for clients to raise other significant issues now they feel more at ease. A pro forma (Figure 3.2) that may assist you with note taking and structuring an interview follows. The text in the right-hand column is a series of prompts and can function as a checklist.

Adapting diagnostic interviews for different client groups (children and the elderly) The diagnostic interview will need to be adapted in a flexible manner to be suitable for each client. However, some general points can be made about certain client groups. One important group to consider is children. When interviewing


Assessing clients

Figure 3.2.

Annotated pro forma of initial interview

children the clinician needs to contextualize the information in the normative developmental process. Deviations from normal childhood development need to be understood both in terms of the normative processes and also in terms of the typical variability (see Sattler, 2001, 2002). Assessments of children may also


Adapting diagnostic interviews for different client groups

require the collection of information from parents, teachers, other family members and professionals. Collection of data from multiple sources provides a rich picture of the problem as well as insight into the way the problematic behaviours are observed and interpreted by individuals prominent in the child’s life (see Sattler, 2001, 2002). When interviewing the elderly, there are a variety of considerations when arriving at a diagnosis. Medical conditions, cognitive impairment, and pharmacological issues may all have a bearing on the client’s presentation (Edelstein et al., 2002). The same disorder does not always present itself in the same way in older adults as it does in younger adults. For instance, depression is more likely to present with somatic symptoms and with less dysphoria (Fiske et al., 1998). Further, the clinician will need to entertain differential diagnostic possibilities among older adults that are less common with younger clients. For instance, depression and dementia can co-occur at times and need to be distinguished (see Edelstein, 1998; Kaszniak & Christenson, 1994). Screening for psychological symptoms

A large amount of information needs to be collected during a diagnostic interview and there is a risk that key issues will be missed. One way to complement the information gleaned from a diagnostic interview is to collect information from screening tests. Screening is the ‘‘presumptive identification of unrecognized disease or defect by the application of tests, examinations or other procedures which can be applied rapidly to sort out apparently well persons who probably have a disease from those who probably do not’’ (Commission on Chronic Illness, 1957; p. 45). Therefore, when administered before a diagnostic interview, they provide the clinician with an efficient means of collecting and collating symptom information, as well as giving an indication of the extent to which a client’s symptom profile deviates from statistical norms. SCL-90-R and BSI

The Revised Symptom Checklist 90 (SCL-90-R: Derogatis, 1994) is a broad symptom measure that covers nine dimensions (Somatization, Obsessive compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, and Psychoticism). Three global indices of distress can be derived from the dimensional scores. The 90 items (or an even briefer version is available in the form of the Brief Symptom Index; BSI, Derogratis & Spencer, 1982) are scores referring to the past 7 days, including today and takes clients about 15 minutes to complete. Responses can be interpreted in terms of the global indices, the nine dimensions, or the items themselves,


Assessing clients

and the chief advantage is that the clinician is provided with a broad range of symptom information in a very efficient manner. General health questionnaire (GHQ)

Developed by Goldberg (1972), the GHQ is a 60-item scale that identifies four factor-analytically derived subscales describing Somatic symptoms, anxiety and insomnia, Social dysfunction, and Severe depression. Briefer forms (GHQ-30 and GHQ-12) are available and the scale has been validated for use among many different samples (including geriatric, traumatically injured and medically ill patients). Centre for epidemiological studies  depression scale (CES-D)

The CES-D is a 20-item self-report scale that assesses mood and functioning over the past 7 days (Radloff, 1977). It identifies Depressed affect, Positive affect, Somatic problems and Interpersonal problems. The scale can be abbreviated to a 5-item version and has been validated in community, medical and clinical samples. Beck depression inventory (BDI)

The BDI (Beck et al., 1961) is a 21-item scale designed to assess the present severity of depression by assessing attitudes and symptoms related to depression, with the latest revision aiming to assess the existence and severity of the DSM’s symptoms of depression (Beck et al., 1996). Cut-off scores of 013 indicate minimal depression, 1419 mild depression, 2028 moderate depression and 2963 severe depression. A number of studies have supported the reliability and validity of the BDI and it is useful for measuring depressive symptoms, indicating the severity of present symptoms, and quantifying the extent of treatment changes (Beck et al., 1988; Sundberg, 1987). Behaviour and symptom identification index (BASIS-32)

Another brief screening instrument is the BASIS-32 (Eisen & Grob, 1989). This 32-item self-report inventory assesses over a 1-week interval the major symptom domains and current function that requires in-patient psychiatric treatment. The subscales measure relation to self and others, daily living and role functioning, anxiety and depression, impulsive and addictive behaviour and psychosis. Hamilton anxiety scale (HAS) and the Hamilton rating scale for depression (HAM-D)

The HAS (Hamilton, 1959) is a 14-item clinician-rated scale assessing the symptoms of anxiety. The subscales are psychic and somatic anxiety. The


Adapting diagnostic interviews for different client groups

HAM-D (Hamilton, 1967) is a 21-item clinician-rated scale. Both of these tests have been used with a wide variety of client groups, they are commonly used and they have good psychometric properties. In summary, each of the preceding scales provides a good screening for psychopathology. They can assist the clinician in recognizing a disorder by making the clinician aware of particular symptoms, as well as their levels and patterns. To date, with the exception of Mental retardation, no diagnosis requires a particular result associated with a certain type of psychometric instrument. There are suggestions that future diagnostic systems may include such tests if substantial gains in reliability and validity occur when the tests are used (Rounsaville et al., 2002). However, none of the screening instruments reviewed can indicate that a client has met diagnostic criteria for a particular disorder. Structured and semi-structured diagnostic interviews serve this function. Structured and semi-structured diagnostic interviews: adults

Any diagnostic method must be both reliable and valid. However, the validity of a diagnostic interview and a diagnostic system are not identical. The validity of a diagnostic interview is judged by the extent to which the outcome of the interview matches onto the disorder in the diagnostic taxonomy. The validity of a diagnostic system is judged by the degree to which the disorders describe clinically meaningful clusters of symptoms. Although reliability does not guarantee validity, validity requires reliability. In the past, diagnoses were notoriously unreliable, but the decision to introduce specific diagnostic criteria for each disorder into the DSM-III (APA, 1980) successfully increased the reliability of diagnoses. Although some have suggested that the validity of the diagnoses themselves was sacrificed in the pursuit of reliability (see Rounsaville et al., 2002), another source of unreliability is the diagnostic interview itself. Clinicians may omit key questions, fail to consider all diagnostic possibilities, or be overly influenced by dramatic symptoms and hence arrive at a diagnosis that would not be obtained by a second interviewer, or even by the same clinician on a separate occasion. One way to increase diagnostic reliability in generating DSM and ICD diagnoses is to use structured and semi-structured diagnostic interviews (Summerfeldt & Antony, 2002). Structured diagnostic interviews are particularly helpful in research (where replicability is essential), in training (where the structure can assist a novice clinician), and in practice (where use of a standardized instrument can increase the confidence in a diagnosis). A variety of instruments are available and they will be reviewed next. There are a set of dimensions along which the instruments vary (e.g., diagnostic breadth and depth, duration of the interview, extent to which clinical skill is required, target population) and thus the individual


Assessing clients

electing to use a structured diagnostic interview will need to consider the purpose of the interview. Specifically, the clinician will need to evaluate the instrument in terms of (i) coverage and content, (ii) the target population, (iii) the psychometric features of the instrument, (iv) practical issues (e.g., duration, training), and (v) administration requirements, and support (e.g., scoring algorithms, standardized manual; see Page, 1991a; Summerfeldt & Antony, 2002). Anxiety disorders interview schedule for DSM-IV (ADIS-IV)

The ADIS-IV (Brown et al., 1994) is a semi-structured interview that follows a structure similar to a clinical interview and relies on the clinician to ask additional questions to follow up issues of relevance. Although its primary focus is the DSM-IV Anxiety Disorders, it also assesses Mood, Substance use, and Somatoform disorders due to their high rates of comorbidity with anxiety. The relatively narrow coverage can be offset by the detailed information provided by the interview about conditions, etiology and dimensional symptom ratings. The whole interview assessing current and lifetime disorders takes 24 hours in clinical samples. The reliability of the instrument is acceptable and the limited validity data upon its predecessor are supportive (e.g., Rapee et al., 1992). In addition to its use in research, the ADIS-IV is suitable as a primary diagnostic measure when used by trained mental health professionals. Diagnostic interview schedule (DIS) and the composite international diagnostic interview (CIDI)

The DIS-IV (Robins et al., 1995) is a structured diagnostic interview that is suitable for use by lay interviewers as well as mental health professionals. The diagnostic coverage is broad and is even broader in the more extensive version; the CIDI (Robins et al., 1988). The most recent version of the CIDI is compatible with both DSM-IV and ICD-10 and therefore is suitable for international comparisons (Andrews & Peters, 1998). Due to their similarity, they will be considered together. The instruments are organized in a modular format to permit customization of the interview and the structured format has permitted computerization. The administration time is 23 hours with clinical samples and they yield both current and lifetime diagnoses. The instruments are useful in large scale epidemiological studies, but the level of agreement with clinical diagnoses is poor and therefore it is recommended that the findings are supplemented with other sources of data (Segal & Falk, 1997). Consequently, they are not suitable as primary diagnostic instruments in psychiatric settings.


Adapting diagnostic interviews for different client groups

Mini-international neuropsychiatric interview (MINI)

The MINI (Sheehan et al., 1999) is a clinician-administered structured diagnostic interview that assesses both DSM-IV and ICD-10 criteria. Being designed to provide a valid structured interview for clinical and research contexts, it covers a broad range of disorders, but does so in around 15 minutes. The reliability and validity of this instrument are promising (Sheehan et al., 1998). Primary care evaluation of mental disorders (PRIME-MD)

In contrast to the preceding interviews, which provide an extensive assessment of many disorders present currently and over the lifetime, the PRIME-MD is a brief (1020 min; or 3 min using the more recent Patient Health Questionnaire; Spitzer et al., 1999) clinician-administered interview to permit primary care physicians to rapidly identify the mental disorders commonly seen in medical practice (Spitzer et al., 1995). Comprising a 25-item, self-report questionnaire asking about general physical and mental health issues and a semistructured interview to follow up on items that the patient has endorsed, the instrument provides a quick assessment of DSM-IV mood, anxiety, somatoform, eating and alcohol-related disorders. Little reliability data exist and in terms of validity, its sensitivity and specificity are good, although the correspondence with DSMIV was only moderate. Although the speed comes at a cost of breadth and depth, and the diagnoses obtained do not map directly onto DSM-IV categories, as a quick standardized identification of psychiatric cases, the instrument performs well. Another instrument that is suitable for use by physicians in primary care is the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC; Broadhead et al., 1995). Schedule for affective disorders and schizophrenia (SADS)

The SADS (Endicott & Spitzer, 1978) is a clinician-administered semi-structured interview developed to assess the research diagnostic criteria (found in the second volume of the ICD-10). The instrument assesses current and past symptoms, with other versions assessing symptoms across the whole lifetime (SADS-L; Lifetime), and changes in symptoms (SADS-C; Change). The SADS has a broad coverage of psychological disorders and the SADS-LA-IV (SADS Lifetime Anxiety for DSM-IV; Fyer et al., 1995 cited in Summerfeldt & Antony, 2002) also assesses DSM-IV criteria in addition to expanded coverage of anxiety disorders. A SADS interview takes an hour with non-clinical samples, and this short duration, relative to its breadth of coverage, is achieved by a structure that permits clinicians to skip sections that are not relevant because the respondent fails to endorse screening questions or they are not germane to the interview purpose. The reliability of the SADS is excellent, when compared with the other


Assessing clients

structured diagnostic interviews (Rogers, 1995) and the validity is very good (see Conoley & Impara, 1995), particularly in the area of mood disorders, making it well-suited as a primary diagnostic screening measure. Structured clinical interview for DSM-IV axis-I disorders (SCID)

The SCID is available in a brief clinical (SCID-CV; First, Spitzer et al., 1997) and a more extensive research (SCID-I; First, Spitzer et al., 1996) version. Importantly, versions are also available for Axis II Personality Disorders. The SCID-CV is a relatively brief interview that provides coverage of the disorders commonly seen in a mental health practice. The SCID-I comes in a variety of forms and the version designed for individuals already identified as psychiatric patients (SCID-I/P) has the most extensive coverage of mental health disorders of all available instruments, with interviews taking at least an hour. The reliability is good (Segal et al., 1994) and validity studies of previous versions have also been supportive of the instrument (Rogers, 1995, 2001). Schedule for clinical assessment in neuropsychiatry (SCAN)

The SCAN (WHO, 1998) is quite different from other structured interviews. Whereas other instruments focus on diagnostic categories, the SCAN seeks to describe key symptoms. The instrument comprises a semi-structured clinical interview, a glossary to rate the experiences endorsed by respondents, a checklist to rate information provided by third parties, and a schedule to assess the respondent’s clinical, social and developmental history. The data can be scored to generate DSM-IV and ICD-10 diagnoses. Structured and semi-structured diagnostic interviews: children and adolescents Child and adolescent psychiatric assessment (CAPA)

The CAPA (Angold et al., 1995) is a structured diagnostic interview suitable for children and adolescents aged 917. It assesses the onset, duration, frequency and intensity of symptoms present in the three months prior to the interview, and permits diagnoses in both DSM-IV and ICD-10 to be made. It has a modular format that permits clinicians to use it flexibly, with the patient report version taking around an hour. The reliability and validity data are good (Angold & Colstello, 2000). Diagnostic interview schedule for children (DISC)

A version of the DIS is available for children and adolescents aged 618 (DISC; see Shaffer et al., 2000). Modelled on the DIS’s highly structured format, it assesses the common psychiatric diagnoses found in children and adolescents.


Adapting diagnostic interviews for different client groups

It has good testretest reliability (appearing to improve with age), but validity studies have been disappointing. Children’s interview for psychiatric syndromes (ChIPS).

The ChIPS (Weller et al., 1999) is a structured interview for use with children and adolescents aged 618, and is available in child and parent versions. Responses to stem questions determine if the interviewer will proceed to follow a particular line of questioning. Psychometric data on this instrument are promising (Weller et al., 2000). Child assessment schedule (CAS)

The CAS (Hodges et al., 1982) is a semi-structured diagnostic interview suitable for children aged 7 and above. Symptoms are assessed in a semi-structured interview with the child and by the interviewer’s observations. Taking around an hour to complete, the psychometric data are good (Broggs et al., 2002). Interview schedule for children and adolescents (ISCA)

The ISCA (Kovacs, 1997) is a semi-structured diagnostic interview suitable for children and adolescents aged 817 years. The instrument provides diagnoses in DSM-IV categories and takes around three hours to complete. Psychometric data are promising (Sherrill & Kovacs, 2000). Schedule for affective disorders and schizophrenia for school-age children (K-SADS)

The K-SADS is a version of the adult SADS that is designed for children of age 6 and above to yield DSM-IV diagnoses. Parent and child response versions are available, and the reliability data are good and validity data are acceptable (Ambrosini, 2000). Structured and semi-structured diagnostic interviews: older adults

Structured diagnostic interviews have not yet been developed specifically for use with older adults and the instruments already discussed can be used. However, mental state can be assessed using the Geriatric Mental State Schedule (GSM; Copeland et al., 1976), and the GMS ScheduleDepression Scale (Ravindran et al., 1994) is a brief semi-structured interview to discriminate between depressed and non-depressed older adults. Other instruments, such as the Comprehensive Assessment and Referral Evaluation (CARE; Gurland et al., 1977, 1984) and the Cambridge Mental Disorders of the Elderly Examination (CAMDEX; Roth et al., 1986) provide assessments of a client’s mental state. The mental state of clients is an important component of an assessment and diagnosis with older adults, but is also relevant with clients


Assessing clients Table 3.1. An outline for a mental status examination.

Physical Appearance Behaviour

Motor activity Emotional


Mood and affect Cognitive

Orientation Memory Thought (form and content) Insight and judgement

Attention and concentration Speech and language Perception Intelligence and abstraction

of any age. Therefore, the assessment of mental state will be considered in some detail. Mental status examination (MSE) The MSE provides a template that assists a clinical psychologist in the collation and subsequent conceptual organization of clinical information about a client’s emotional and cognitive functioning. By systematically basing observations on verbal and non-verbal behaviour, the aim is to increase the reliability of the data upon which subsequent diagnoses and case formulation are made. The particular perspective of the interview and the use to which the data are put will vary depending upon whether the goal is psychiatric (see Daniel & Crider, 2003; Treatment Protocol Project, 1997) or neurological (see Strub & Black, 2000), but the domains covered by the clinician are similar. Reporting an MSE also requires the clinician to be familiar with the descriptors of various symptoms, such as those found in the glossary of the DSM-IV-TR (APA, 2000; see also Kaplan & Sadock, 2004). Broadly speaking (and following Daniel & Crider, 2003), a MSE collates information about the client’s (i) physical, (ii) emotional, and (iii) cognitive state. Under each of these domains fall a number of topic areas which are summarized in Table 3.1 The summary of an MSE will not note every detail under each heading, but draws attention to the key features that describe the client and frame the presenting problem within a context of who the client is. Typically, the description begins with a statement about their age, gender, relationship status, referrer and presenting problem (i.e., the reason for presentation at the service on the


Mental status examination (MSE)

particular occasion). For instance, the description may begin by saying, ‘‘Gill, a 35-year-old self-referred single woman was referred by her medical practitioner who had suggested treatment for her obesity that was contributing to hypertension’’. Physical

The description will draw attention to noteworthy aspects of the client’s physical state. Appearance

A concise summary of the client’s physical presentation is given to paint a clear mental portrait. The description may refer to dress, grooming, facial expression, posture, eye contact, as well as any relevant noteworthy aspects of appearance. For instance, a clinician might note that the client ‘‘wore an expensive, but crumpled suit. He sat slumped in the chair and was unshaven, with dark circles under his eyes’’. Importantly, the aim is to describe what is observed rather than your interpretation (e.g., ‘‘he was exhausted’’). Behaviour

A description of behaviour may make reference to the client’s level of consciousness extending from alert through drowsy, a clouding of consciousness, stupor (lack of reaction to environmental stimuli) and delirium (bewildered, confused, restless and disoriented), to coma (unconsciousness). It may also include reference to the degree of arousal (e.g., hypervigilance to environmental cues and hyperarousal such as observed in anxious and manic states), mannerisms (e.g., tics and compulsions). Motor activity

An account of the observed motor activity aims to describe both the quality and the types of actions observed. Reductions in movement can be variously described as a reduction in the level of movement (psychomotor retardation), slowed movement (bradykinesia), decreased movement (hypokinesia), or even an absence of movement (akinesia). Increases in the overall level of movement are referred to as psychomotor agitation, but it is also important to note minor increases in movement such as a tremor. Emotional

Moving from the physical domain, the clinician will portray the person’s emotional state, once again drawing upon the verbal and non-verbal behaviour of the client.


Assessing clients


The clinician will also consider the way in which the client participates in the interview as a way of gauging their manner and outlook. These judgments will be based on the client’s response both to the context of the interview and also to the interviewer. Identifiers may be open, friendly, cooperative, willing and responsive, or alternatively, they may be closed, guarded, hostile, suspicious and passive. These terms will be used to describe complex sets of behaviours including attentiveness, responses to questions, expression, posture, eye contact, tone of voice, and so on. Mood and affect

Although affect (an external expression of an emotional state) is potentially observable, mood (the internal emotional experience that influences both perception of the world and the individual’s behavioural responses) is less apparent and will require the clinician to depend to a greater degree on the client’s introspections. Descriptors of mood include euphoric, dysphoric (sad and depressed), hostile, apprehensive, fearful, anxious and suspicious. The stability of mood can also be noted, with the alternation between extreme emotional states being referred to as emotional lability. The range, intensity and variability of affect can be variously portrayed, but some important expressions are restricted (i.e., low intensity or range of emotional expression), blunted (i.e., severe declines in the range and intensity of emotional range and expression), flat (i.e., a virtual absence of emotional expression, often with an immobile face and a monotonous voice) and exaggerated (i.e., an overly strong emotional reaction) affect. The clinician will also consider the appropriateness of the affect (and note if the emotional expression is incongruent with verbal descriptions and behaviour) as well as the client’s general responsiveness. Cognitive

The cognitive components in an MSE will be familiar to clinical psychologists, since many components are assessed more comprehensively and within memory tests. However, during the MSE, the aim is to provide a general screening which requires interpretation using clinical judgement, with one outcome being to recommend further formal testing. Orientation

A person’s orientation refers to their awareness of time, place and person. Orientation for time refers to a client’s ability to indicate the current day and date (with acceptance of an error of a couple of days). Orientation for place can


Mental status examination (MSE)

be assessed by asking clients where they have presented. Behaviour should also be consistent with that expected in the setting in which they have arrived. Orientation for person refers to the ability to know who you are, which can be assessed by asking the client their name or names of friends and family which you can verify. Attention and concentration

Working memory (Baddeley, 1986, 1990) is the term now used in psychology to refer to the constructs called attention and concentration. The aim is to describe the extent to which a client is able to focus their cognitive processes upon a given target and not be distracted by non-target stimuli. Digit span (the ability to recall in forward or reverse order increasingly long series of numbers presented at a rate of one per second) is a common way to assess these working memory functions, and normal individuals will recall around 68 numbers in digits forward and 56 numbers in digits backwards. Another method used is serial sevens in which seven is sequentially subtracted from 100. Typically people will make only a couple of errors in 14 trials. Memory

An MSE will typically assess memory using the categories of short-and long-term memory. Although these categories do not map neatly onto models of memory in recent cognitive psychology (Andrade, 2001), the aim of the MSE is to provide a concise description of a person’s behaviour and screen them in a manner that can guide further assessment. Therefore, more sophisticated assessments and analyses may follow. To assess recent or short-term memory, clients can be asked about a recent topical event or who the President or Prime Minister is. Clients can also be asked to listen to three words, repeat them, and then recall them some time later in the interview. Most people will usually report 23 words after a 20-minute interval. Visual short-term memory can also be assessed by asking clients to copy and then reproduce from memory complex geometrical figures (such as those in the Rey Auditory Verbal Learning Test). Long-term memory can be assessed by asking about childhood events. Thought  form and content

During an MSE the clinician will address the client’s thought processes, inferred typically from speech. Disturbances in the form of thought are evident in terms of the (i) quantity and speed of thought production. The client may jump from idea to idea (flight of ideas) or show a poverty of ideas. Thought may be disordered in terms of (ii) the continuity of ideas. The client may leave a topic


Assessing clients

of conversation and perhaps return to it much later (circumstantiality), or maybe never return (tangentiality) or may perseverate with the same idea, word or phrase. They may show a loosening of associations, where the logical connections between thoughts are esoteric or bizarre. Problems in the content of thought also need to be noted by a clinician. Delusions are profound disturbances in thought content in which the client continues to hold to a false belief despite objective contradictory evidence, despite other members of their culture not sharing the same belief. Delusions vary on dimensions of plausibility, from the plausible (e.g., the CIA is spying on me) to the bizarre (e.g., the newspaper contains coded messages for me), and systematization, from those that are unstable and non-systematized to stable and systematized. The content of delusions can be persecutory (others are deliberately trying to wrong, harm or conspire against another), grandiose (an exaggerated sense of one’s own importance, power or significance), somatic (physical sensations or medical problems), reference (belief that otherwise innocuous events or actions refer specifically to the individual), control, influence and passivity (belief that thoughts, feelings, impulses and actions are controlled by an external agency or force). Clients can also have delusions that are nihilistic (belief that self or part of self, others, or the world does not exist), jealous (unreasonable belief that a partner is unfaithful), or religious (false belief that the person has a special link with God). The clinician needs to consider cultural factors as well as other clinical issues in identifying delusions. For example, belief in the sovereignty of God is not a delusion of control, because this is shared by others within a culture. Also, oversensitivity to the opinions of others is not a delusion of jealousy, since clients will typically not hold the belief in the face of contradictory evidence (behavioural experiment reference) and can concede that it is conceivable that the belief is wrong. Although the distinction between strongly held false beliefs and delusions is sometimes difficult, the clinician will find it easier if the focus remains on the chain of reasoning whereby a person comes to believe a particular false belief rather than solely relying upon the content of the belief. In addition to these extreme forms of thought disturbance, there are more frequent issues such as phobias (excessive and irrational fears), obsessions (repetitive and intrusive thoughts, images or impulses), and preoccupations (e.g., with illness or symptoms). Perception

Hallucinations are a perceptual disturbance in which people have an internally generated sensory experience, so that they hear, see (visual), feel (tactile), taste (gustatory), or smell (olfactory) something that is not present or detectable


Mental status examination (MSE)

by others. The most frequent hallucinations are auditory and typically involve hearing voices, calling, commanding, commenting, insulting or criticizing. Hallucinations can also occur when falling asleep (hypnogogic) or when awaking (hypnopompic). Other perceptual disturbances include a sense that the external world is unreal, different or unfamiliar (derealization), an experience that the self is different or unreal in that the individual may feel unreal, that the body is distorted or being perceived from a distance (depersonalization). Perceptions can also be dulled, in that perceptions are flat and uninteresting, or heightened, in that each perception is vivid. Insight and judgement

Insight is a dimension that describes the extent to which clients are aware that they have a problem. A strong lack of insight can be an important indicator of unwillingness to accept treatment. Insight refers also to an awareness of the nature and extent of the problem, the effects of the problem on others, and how it is a departure from normal. For instance, clients may deny the presence of a problem altogether, or may recognize the problem, but judge the cause to lie within others. Judgement is another issue that the clinician will consider during an MSE. The ability to make sound decisions can be compromised for a number of reasons. The clinician will try to ascertain if poor decisions are the result of problems in the cognitive processes involved in the decision-making process, motivational issues, or failures to execute a planned course of action. Speech and language

A client’s speech can be described in terms of its rate (e.g., slow, rapid), intonation (e.g., monotonous), spontaneity, articulation, volume, as well as the quantity of information conveyed. At one end of the dimension of information conveyed is mutism (i.e., a total absence of speech), extending through poverty of speech (i.e., reduced spontaneous speech) to pressured speech (i.e., extremely rapid speech that is hard to interrupt and understand). Speech is a subset within the broader domain of language. Language also includes reading, writing and comprehension. Cognitive dysfunctions can be indicated by language disturbances (see Lezak et al., 2004 for an extended discussion) such as aphasia. Aphasia can be non-fluent, in which speech is slow, faltering, or effortful or fluent. Fluent aphasia involves speech that is normal in terms of its form (rhythm, quantity and intonation), but is meaningless, perhaps including novel words (i.e., neologisms).


Assessing clients

Intelligence and abstraction

A general indication of intelligence can be gained from the amount of schooling a person has had, with a failure to complete high school indicating below average intelligence, completion of high school indicating average intelligence and college or university education indicating high intelligence. Abstraction is the ability to recognize and comprehend abstract relationships  to extract common characteristics from a group of objects (e.g., in what way are an apple/banana or music/sculpture alike?), interpretation (e.g., explaining a proverb such as a stitch in time saves nine). However, care needs to be exercised interpreting responses to abstract questions, since they may reflect the degree to which the person’s cultural group has permitted exposure to the content of the sayings. Summary

An MSE provides a useful conceptual organization for the clinician and a mental checklist to consider a client’s functioning across broad domains. During a diagnostic interview it would be rare to systemically work through each area, but relevant questions are included as judged appropriate. Brief, formal versions with standard scoring of the MSE are available in the Mini Mental State Exam (Folstein et al., 1975; see also Treatment Protocol Project, 1997). It is an 11-item scale to measure orientation, registration, attention and calculation, recall, language and praxis. Scores range from 0 to 30 and lower scores indicate greater impairment. The chief problem is that it is less sensitive for cases with milder impairment and scores are influenced by educational level of the subject. Some other options are: the Cognitive Capacity Screening Examination (CCSE; Jacobs et al., 1977), a 30-item screener to detect diffuse organic disorders, especially delirium, that is more appropriate for cognitively intact individuals; the High Sensitivity Cognitive Screen (HSCS; Faust & Fogel, 1989), a 15-item scale that is a valid and reliable indicator of the presence of cognitive impairment; the Mental Status Questionnaire (MSQ; Kahn et al., 1960), a 10-item scale that shares the same weaknesses as the MMSE and omits some key domains of function (e.g., retention and registration); and the Short Portable Mental Status Questionnaire (SPMSQ; Pfeiffer, 1975), a 10-item scale for use with community or institutional residents that is a reliable indicator of brain injury.

Limitations of diagnosis and future directions Diagnosis is important because without it, the social processes required for delivery of mental health services could not be justified, research would be


Limitations of diagnosis and future directions

hampered, and communication among professionals and information retrieval would be difficult. However, this is not to say that current diagnostic systems are without fault. Rather, the clinician needs to be cognizant of these weaknesses and use diagnoses accordingly. First, following the introduction of specific criteria and a focus on observable (rather than inferred) symptoms, the reliability of diagnoses has increased. However, the validity of some diagnoses has been called into question. A problem with the diagnostic system is that the confidence in the validity of each diagnosis is not specified, yet not all diagnostic categories are equally valid. Second, generally there are no identifiable psychometric assessments that relate to particular diagnoses. Thus, the clinician will need to evaluate the available psychological tests and determine which tests, and which normative groups and cut-offs, are relevant for supplementing a diagnosis. Third, the diagnostic system is focused upon existing disorders and makes no reference to precursors to particular disorders. With the increasing focus on prevention and early intervention, the clinical psychologist needs to remember that there may be good reasons for intervening in specific problem behaviours, even though they may not be listed in DSM-IV-TR or ICD-10. Fourth, many psychological models of psychopathology are dimensional and the etiological processes are found in both normal and abnormal populations, but to varying degrees. The DSM and ICD systems are both categorical systems that identify the presence of a disorder rather than locating an individual upon a dimension. Within the area of personality disorders, there is increasing awareness of the need to consider psychopathology in a dimensional manner. For the clinical psychologist, this is relevant, as the clinician will not solely be searching for qualitatively different processes, but trying to identify the extent to which behaviour, cognition and physiology are disturbed. Fifth, it is critical for clinical psychologists to remember that many problems worthy of intervention and treatment are not listed as clinical disorders within diagnostic systems. Relational disorders (First et al., 2002), such as couple distress, are just one example of the disorders that do not fit within the focus of current diagnostic taxonomies upon the individual, rather than a dyad, family system, or other social group. Finally, perhaps the most serious criticism of the diagnoses arrived at using current diagnostic systems is that they are limited predictors of treatment outcome (Acierno et al., 1997). Ultimately, diagnostic systems are valuable if they can predict treatment response. Symptoms are one factor that determines outcome, but not the sole predictor. However, the DSM-IV, the ICD-10 and the empirical literature tend to focus almost exclusively upon this dimension. Further, the assignment of a DSM or ICD diagnosis does not regularly imply that a specific intervention is indicated (see Nathan & Gorman, 2002). From the


Assessing clients

perspective of a clinical psychologist, the absence of indices other than symptoms is disturbing. Most psychological models of psychopathology acknowledge the important etiological role of stressful life events (Miller, 1996), yet these factors are absent from diagnoses. Alternative axes have been proposed, including suggestions to measure (i) symptoms of behaviour, cognition and physiology through behavioural observation, self-report, and physiological monitoring (Bellack & Hersen, 1998), (ii) maintaining factors through a functional analysis of contingencies of reinforcement and other contextual factors, and (iii) etiology (see Acierno et al., 1997). Although suggestions for revision to the DSM-V include recommendations to form etiological diagnostic systems (primarily based on neuroscience; Charney et al., 2002) this seems unlikely to be successful for two reasons. First, neuroscience presently remains too imprecise to provide a sufficiently solid foundation to achieve the ‘‘goal to translate basic and clinical neuroscience research relating brain structure, brain function, and behaviour into a classification system of psychiatric disorders based on etiology and pathophysiology’’ (Charney et al., 2002; p. 70; e.g., there is still no biological marker for any psychiatric diagnosis), and second, it fails to acknowledge that there are social and psychological factors that exert important and complicated effects. For instance, Gil et al. (2000) have shown that higher rates of alcohol use by US-born Latino adolescents compared with recent immigrants are associated with the reduction over time in familism, cohesion and social control. Thus, it seems unlikely that diagnostic taxonomies in the near future will incorporate factors such as a comprehensive symptom assessment, a systematic examination of maintaining factors, personality and consideration of various aspects of etiology. Nonetheless, there is room within a clinical intervention to address these important factors and this will be the focus of Chapter 4.

Additional assessment and testing Reviewing our model (Figure 3.3), it is apparent that assessment may begin concurrently with diagnosis, but it extends far beyond. The clinical psychologist (i) distils information into a case formulation, (ii) assists treatment planning in which interventions are matched to clients, and (iii) measures the degree of success. The process of assessment is indicated by the shaded area and the process is divided into matching, measurement and monitoring which are located within an overall management structure. . Management of outcomes involves the ongoing assessment and evaluation of clinical and administrative processes involved in the delivery of care.


Additional assessment and testing

Figure 3.3.

The centrality of assessment processes and techniques to the scientific practice of clinical psychology (shaded area indicates the components involving assessment)

. Matching refers to the process of matching the client to the appropriate

treatment option. This process begins with screening and problem description which have been discussed earlier. Problem description is followed by treatment planning or matching (in which specific information is collected that aids the clinical decision-making process). Once the problem has been accurately identified the psychologist can give thought to the most appropriate treatment (Beutler & Clarkin, 1990; Beutler & Harwood, 2000; Castonguay & Beutler, 2006). Sometimes the relevant treatment will be evident by examining a list of empirically-validated treatments (e.g., Nathan & Gorman, 2002). However, at other times the picture will be more complicated, due to patterns of comorbidity and involved presentations. At these times case formulation can be used to identify potential treatments that are linked to the causal mechanisms involved. . Measurement involves the pre, post and follow-up assessments of a variable(s) to determine the amount of change that has occurred as a result of an intervention.


Assessing clients

. Monitoring refers to the periodic assessment of intervention outcomes to

permit inferences about what has produced observed changes. Progress monitoring determines deviations from the expected course of improvement; whereas outcomes monitoring focuses upon the aspects of the intervention process that bring about change. Thus, these four activities all occur within a context of empirically-derived and supported assessment. Although the concept of measurement will be familiar to a psychologist, ongoing monitoring may be less familiar. Lutz et al., (1999; see also Asay et al., 2002; Lutz et al., 2002) distinguished treatment-focused research from patient-focused research. Patient-focused research, what we have called monitoring, asks the question, ‘‘Is this particular client’s problem responding to the treatment that is being applied?’’ (Lutz et al., 1999). Thus, with the move from treatment-to patient-focused research, the spotlight shifts from the average client to the particular individual currently being treated. Before describing some general principles of monitoring, a scientistpractitioner needs to consider the empirical evidence regarding monitoring. Monitoring will take time and effort on the client’s part and the clinician will need to collect, score, store, collate, interpret and feedback all data to the client. Therefore, the clinician needs to be able to justify to the client, themselves and their employer the costs incurred. To this end, work by Lambert et al. (2001) is useful. They assigned clients to treatment as usual or a condition in which their clinician received weekly feedback on their symptom change relative to expected progress. The sample was then divided into clients who were predicted to have good versus poor outcomes, based on initial assessment. For clients who were predicted to have poor outcomes, treatment duration increased and the outcomes were improved, such that twice as many clients achieved clinically significant (Jacobson & Truax, 1991) change. For clients who were expected to have a positive response to treatment, the outcomes were no better, but the number of sessions was reduced. Therefore, the provision of monitoring data to the clinicians allowed them to target therapy time to clients where it was most needed and in so doing, maximized the overall benefit. Monitoring of clients highlights the various phases of treatment. Lutz et al. (1999, 2002) identify three phases to therapy. The client passes through remoralization, as subjective well-being improves, remediation, as symptoms begin to reduce, and rehabilitation, as the improvements in well-being and symptoms spread to domains of life functioning. The process of symptom amelioration will follow a log linear curve for the average client (Howard et al., 1986), such that the greatest change occurs in the initial sessions, with improvement gradually flattening out. If assessments are collected during treatment (e.g., the COMPASS tracking system; Howard et al., 1995; Sperry et al., 1996), it is possible


Additional assessment and testing

to plot an expected course of recovery using a variety of predictor variables. For instance, Lutz et al. (1999) used archival data on subjective well-being, current symptoms, current life functioning, global assessment of functioning, past use of therapy, problem duration and treatment expectations to generate an expected treatment trajectory. Using a client’s pre-treatment scores it is then possible to plot an expected course of improvement for each particular client, over which can be overlaid actual progress. Placing boundaries around the expected trajectory of improvement shows that a lower range is set by the failure boundary (e.g., scores of clients in the 25th percentile) and an upper range (e.g., mean scores of non-clinical sample). As a result, it is possible to display a graphical depiction of a client’s progress through therapy relative to their expected course. Further, as the client’s actual scores approach the normal range, the clinician will receive feedback that treatment is progressing optimally. On the other hand, if a client’s scores approach the failure boundary, the clinician will be alerted that the treatment outcome is not optimal and an alternative treatment plan may need to be set (see Lambert et al., 2001 for another way to depict treatment change and use the data to modify therapy accordingly and Mintz & Kiesler, 1982 for a discussion of individualized outcome measures in psychotherapy). Thus, repeating testing during an intervention can provide an indication of the extent to which a person is changing according to expectations. Sometimes this is talked about as a glide path. In the same way that an airplane approaches a runway along a glide path and deviations from the expected trajectory signal time for corrective action, the place where an individual is along a treatment trajectory provides useful information. Deviations from the expected path of improvements may signal a problem. The expected changes in symptom severity, social function and occupational performance can all be monitored against normative references to identify if remedial action is appropriate. Although these approaches to monitoring are more recent than efficacy and effectiveness research, the client-focused research approach typified by monitoring has great potential to bridge the gap between science and practice. Science, by its nature, is concerned with generalizable results, whereas clinical practice is concerned with the instance. By increasing the relevance of data collection to the individual client, monitoring strategies will allow clinical psychologists to collect client-relevant data that can be integrated with data available from treatmentrelevant efficacy and effectiveness research. Furthermore, monitoring permits a science-informed practitioner to test and evaluate hypotheses about each client. The process of forming these hypotheses is the topic of the next chapter.


Linking assessment to treatment: case formulation

Case formulation is a, . . . hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal, and behavioural problems. A case formulation helps organize often complex and contradictory information about a person. It should serve as a blueprint guiding treatment, as a marker for change, as a structure for enabling the therapist to understand the patient better. A case formulation should also help the therapist anticipate therapy-interfering behaviours and experience greater empathy for the patient . . . broadly, a psychotherapy case formulation also includes descriptive information on which the hypothesis is based and prescriptive recommendations that flow from the hypothesis (Eells, 1997a; p. 2; italics in original).

The above quote by Eells highlights that a case formulation links the client and his or her problems with the treatment. It captures both the strengths and the weaknesses of the client, thereby placing the problem and the potential resolution in the context of the whole person. To use a metaphor, if the treatment is the locomotive and the client’s problems are the carriages, then the case formulation is the coupling that holds the two together. Without the coupling, a treatment might chug along nicely but it will fail to bring about any movement in the problems. Clients present to a professional psychologist with a large quantity of information. There is information specific to the presenting problem, but there is also historical, familial, demographic, cultural, medical, educational and social information. Some of this ancillary information will have direct bearing on the presenting problem, some will provide a background and context to the problem, and other information will be largely irrelevant to the problem. The psychologist’s task is to distill the relevant information quickly and efficiently into a treatment plan. It is the case formulation that provides the link. As shown in Figure 4.1, information about a client passes through the lens of the theoretical and empirical literature and is channelled into a case formulation. The case


Behavioural case formulation: functional analysis

Figure 4.1.

The process of linking client data to treatment decisions using case formulation

formulation provides the coupling between diagnostic and assessment information and clinical decisions about treatment planning. Case formulation itself can be broken down into the seven steps illustrated in the callout box in Figure 4.1 and described later in this chapter. As indicated by the two-way arrows, case formulation is not a one-off event. The process of assessment, formulation and treatment planning continues to cycle throughout therapy as a client’s progress is measured and monitored. While there are a variety of psychotherapy case formulations, they typically share much common ground (see Eells, 1997b). We will begin with a behavioural functional analysis, extend this model to include cognitions, and then consider case formulations from an interpersonal psychotherapy perspective as these specifically include interpersonal aspects in the formulation. Behavioural case formulation: functional analysis One area where the core elements of a behavioural case formulation have been used with great success is in the area of developmental disabilities. Behavioural case formulation uses hypothesis-driven approaches to identify the function of


Linking assessment to treatment: case formulation

a given behaviour and then uses this understanding in planning treatment (Repp et al., 1995; Turkat, 1985). This approach has received empirical support, such as from Carr et al., (1990), who noted that the success with non-aversive treatments was higher when the treatment was based upon an assessment of the functional relationship between environmental variables and the problem behaviours (see also Schulte, 1997). This analysis of functional relationships is called a functional analysis. A functional analysis involves the identification of important, controllable, causal functional relationships applicable to a specified set of target behaviours for an individual client (Haynes & O’Brien, 1990). Let us examine each component of the definition in turn. The causal variables must be important and controllable. In other words, they need to explain a relatively large proportion of the variance and variables that explain larger portions of the variance are probably going to be more useful in treatment. They must also be controllable. For instance, a history of child abuse may be an important causal variable in the psychopathology of an adult client, but because it is no longer controllable (for this particular individual) it is not going to be an appropriate target for intervention. The aim of a functional analysis is not to explain behaviour in terms of identifying all of the important causal variables, but the aim is to identify those that can be manipulated (i.e., those under control of client and/or therapist). The purpose of identifying causal variables is so that you know which ones to modify. Thus, the focus is upon the effects treatment has on the target behaviour. This target behaviour will exist within a broader array of behaviours. Ultimately, these behaviours exist within social systems and therefore, a functional analysis will require a consideration of the action of any changes on other aspects of the system and the bidirectional effects that these will have upon the target behaviour. In practice, the chief elements of a functional analysis involve identifying three sets of variables; A for Antecedents, B for Behaviours, and C for Consequences (see Figure 4.2). The first set of variables in the functional analysis comprises the antecedents. The antecedents are those variables which are both proximal in time and those which are more distal to the behaviour. Identification of the antecedents also separates the variables that were important in the origin of the problem as distinct from those which are involved in the maintenance of the problem. Antecedents can also be divided into those which are moderators or mediators. Moderators have a direct effect on the behaviour in question, whereas mediators serve to influence a relationship between two variables. For example, a stressor such as a threatened assault might have a direct (or moderating) effect upon anxiety, whereas cognitions about being helpless in the face of possible death during the threat would have an indirect or mediating effect on anxiety.


Behavioural case formulation: functional analysis

Figure 4.2.

The three main components of a functional analysis

The worrying thoughts would mediate the relationship between the threat and anxiety, by amplifying the influence of the threat upon the anxiety response. The second set of variables examined in a functional analysis is the behaviour itself. The behaviour can be described in terms of its frequency, duration, intensity and topography (such as the typical and more unusual patterns). Behaviours can also be examined in terms of their temporal sequence, their history and their relationships with other behaviours. While the term behaviour may conjure up images of actions, the term is typically used broadly to include physiological responses and cognitions. The final components of a functional analysis are the consequences of any behaviour. Traditionally, consequences have been divided into four categories based upon whether the event is turned on or off, and whether the behaviour increases or decreases (see Figure 4.3). When the onset of an event causes an increase in a behaviour, the event is said to be a positive reinforcer. For instance, if a teacher responds with attention each time an otherwise disruptive child sits in his seat, the likelihood of in seat behaviour will be increased. Positive reinforcers do not necessarily need to be pleasant. However, many pleasant events do make effective positive reinforcers. When the onset of an event causes a decrease in behaviour, the event is called a punisher. For example, if a parent responds with criticism and ridicule every


Linking assessment to treatment: case formulation

Figure 4.3.

Four categories of behavioural consequences

time a child plays a wrong note on a musical instrument, the probability of the child continuing to play the instrument is reduced and the ridicule and criticism would be defined as punishment. Once again, just as positive reinforcers do not necessarily need to be pleasant, punishers do not need to be aversive, but many aversive events make effective punishers. When the offset of an event causes an increase in behaviour, the event is said to be a negative reinforcer. For example, drinking alcohol in the early morning to alleviate the hangover effects of a previous night’s excessive drinking increases the probability of future early morning drinking. Finally, when the offset of an event causes a decrease in some behaviour, this is called response cost. An example of a response cost is when the frequency of a child’s shouting in class is reduced as a consequence of not permitting her to play during the lunch hour. The removal of the break was the cost incurred each time the child made the undesirable response and hence the behaviour would decline. These four categories of behavioural consequences appear straightforward, but warrant careful reflection. Consider your response if you heard on breakfast radio that you could win $1,000 if you were the first caller to correctly identify the number of Australian Prime Ministers to date. You might well feel inclined to call up and have a guess, even if you were not sure; after all you have nothing to lose and $1,000 to gain. Now compare how you might respond if you opened a letter from a radio station which contained $1,000 for you to keep and the accompanying letter asked you to call the station and let them know how many British Prime Ministers or American Presidents there have been to date. The letter noted that if you were incorrect, then you would be required to return the money. Presumably, you would put the money into your wallet and not risk losing the money by calling the radio station and giving the wrong answer.


Behavioural case formulation: functional analysis

The first example was an instance of positive reinforcement and the second was an instance of response cost. If your reactions were similar to those described you would agree that in this context, the positive reinforcer encouraged (guessing) behaviour, whereas response cost inhibited (guessing) behaviour. Therefore, if you were identifying consequences that might be beneficial for a socially anxious girl and an impulsive boy, you might well choose to implement positive reinforcement as a way to draw out the girl and use response cost to curb the impulsiveness of the boy. These concepts have been applied in the area of developmental disabilities to understand the existence of many problem behavioural excesses, such as self-injurious behaviour. In identifying the reasons for a behaviour three variables have been identified as important when making case formulations. These three variables are (i) positive reinforcement, (ii) negative reinforcement, and (iii) automatic reinforcement (Iwata et al., 1990; also called stimulation by Carr, 1977). The third category of automatic reinforcement refers to the strengthening of behaviour by the consequences directly produced by a behaviour. Examples of this behaviour include rocking and rhythmic or repetitive behaviours. Technically, these behaviours could be explained in terms of the four types of reinforcement outlined in Figure 4.3, but the term is useful for describing situations where there does not appear to be any reinforcement being derived from the external environment. In the instances described, the sensory feedback itself appears to be reinforcing, so that when the sensory feedback is removed, the behaviour is extinguished (e.g., Rincover, 1978). To identify the function of behaviour one can use three methods of assessment. First, the psychologist can use indirect assessments. Indirect assessments depend on questioning an observer about the occurrence and non-occurrence of the behaviour in question. These can be done with unstructured interviews or with the use of structured questionnaires (e.g., O’Neill et al., 1990; Durand & Crimmins, 1988). Second, the psychologist can use analogue assessments, in which artificial conditions are constructed to test hypotheses about the hypothesized reinforcers. For instance, a control condition can be contrasted with situations involving negative reinforcement, positive reinforcement and automatic reinforcement and the influence upon the behaviour of the schedules of reinforcement can be measured. The results of such an assessment might identify the reinforcer controlling a given behaviour (e.g., Iwata et al., 1982). Thirdly, the psychologist may identify the reinforcement contingencies that are in operation by conducting naturalistic assessments. That is, the behaviour is observed in its natural setting, and changes in the frequency and topography are measured as different contingencies occur (or are established).


Linking assessment to treatment: case formulation

A case example

This adaptation of functional analysis applied in the context of developmental disabilities can be illustrated by considering the presence of problem behaviours in a child with self-injurious behaviour. A 7-year-old boy, Sebastian, with severe mental retardation came to the attention of the psychologist following referral by the teacher. Sebastian would engage in tantrums that involved screaming and self-injury. The psychologist began with an interview with the teacher to obtain a description of the problem behaviour. The teacher described that he would suddenly begin to scratch at his face and forearms, beginning by pinching and squeezing the skin, which could escalate into banging his head and face with his hands. Thus, the psychologist had developed a description of the problem behaviour and thus, it was necessary to identify the antecedents of the problem behaviour. To this end, the teacher had reported that these outbursts occurred infrequently during classtime, but were most common during breaks and lunchtime. However, she was unclear what consequences were maintaining the behaviour. Therefore, the psychologist then collected baseline data, recording the events that occurred during each break (since this was the time with the most likelihood of observing the behaviour) and then calculating the probability of the behaviour’s occurrence and non-occurrence in a 1-minute interval. These formal assessments revealed that the probability of self-injurious behaviour was more probable (i.e., 62%) when the supervising teacher was attending to another child. The probability of self-injurious behaviour was less probable (i.e., 38%) when the supervising teacher was only observing the other children or attending to Sebastian. Thus, a working hypothesis was formed that there was a relationship between the self-injurious behaviour and the perceived withdrawal of attention. To test this working hypothesis, an additional teacher was assigned at one break, who then spent the time ensuring that his attention was allocated to Sebastian. When this occurred, the probability of self-injurious behaviour dropped to 0%, thus giving the psychologist confidence in the working hypothesis. This last component of the functional analysis, when the psychologist tests the working hypothesis by manipulating contingencies is referred to as clinical experimentation by Turkat & Maisto (1985). This step can often be overlooked since it takes time and effort to test a working hypothesis. However, it represents a sound step for clinical practice. Without testing in a potentially accountable manner, the risk is that a treatment strategy will be embarked upon that is misguided and potentially ineffective. If the psychologist waits for the outcome of treatment to gauge validity of the formulation, then it may well be too late, as the client has decided that therapy is ineffective and dropped out or changed psychologists.


Cognitive behavioural case formulation

In summary, a functional analytic strategy identifies the Antecedents of a Behaviour and its Consequences. The consequences are divided into four categories, namely positive reinforcement, punishment, negative reinforcement, and response cost. A working hypothesis is then developed and tested that identifies which particular contingency is related to the problem behaviour. At this point a treatment will be developed which will aim to modify the contingencies that are controlling the problem behaviour. Functional analyses have been useful in the domain of developmental disabilities, but their usefulness is much broader (e.g., see a discussion by Ward et al., 2000 of formulation-based treatments for sexual offenders). Although a very powerful clinical tool (Wolpe & Turkat, 1985), one limitation of a functional analysis is that it does not make reference to the cognitions that may occur between the antecedent and the consequence.

Cognitive behavioural case formulation Persons (1989, 1993; Persons & Tompkins, 1997) outlined a popular approach to case formulation that extends upon the functional analysis described in a number of ways. The most obvious extension is that it includes an assessment of cognitive beliefs and attitudes (see Beck, 1995; Freeman, 1992, Muran & Segal, 1992, Turkat & Maisto, 1985 for other examples). We will first review Persons’ model and indicate where it overlaps with or complements a functional analytic strategy. Following identifications of some limitations of her approach we will outline ways to address these limitations. Problem list

Persons and Tompkins (1997) suggest that a cognitive behavioural case formulation begins with a problem list. This is a comprehensive, descriptive, concrete list of the presenting problem(s) and any other difficulties that the client may have. The emphasis is upon the comprehensive nature of the list, in order to ensure that no difficulty is omitted or overlooked. In the language of the functional analysis introduced earlier, the problem list is analogous to the Behaviour of the ABC. Core beliefs

The next component of the case formulation is a set of hypotheses about the cognitions or beliefs that could explain the origins or the maintenance of some or all the problems in the problem list. The explicit reference to cognitions


Linking assessment to treatment: case formulation

represents an important extension over the functional analytic strategy, which was silent with regard to the potential mediational role of cognitions. Precipitants and activating situations

Precipitants are analogous to the Antecedents within functional analysis. That is, precipitants are the events or stimuli that cause the particular problem in a particular context. Activating situations are also antecedents, but refer to those that explain the problem more generally and explain the consistency across situations. Working hypothesis

Unlike the functional analytic approach, Persons and Tompkins (1997) make no explicit statement about the consequences of a given behaviour, triggered by a particular precipitant, and mediated by a set of beliefs. Instead, they suggest that the clinician develops a theory that links the problems, the core beliefs and the activating events and situations. Origins

The psychologist then outlines early events that might explain the origin of core beliefs. These include predisposing variables, such as early experiences of parental loss or failure that may set the stage for later pathology by creating expectations of abandonment or hopelessness. Treatment plan

Persons and Tompkins (1997) rightly note that a treatment plan is not a component of a case formulation, but they suggest that since a treatment plan will flow from the working hypothesis, it is an aid to good clinical practice to get into the habit of including the plan alongside the hypothesis. Predicted obstacles to treatment

Finally, the psychologist is encouraged to explicitly use the problem list, core beliefs and working hypothesis to identify predicted obstacles to treatment. These may refer to potential difficulties in the therapeutic relationship, compliance with treatment strategies, abilities understanding psychoeducation or interpretations of the problems, recruiting motivation, and so on. The psychologist can then identify ways to address these obstacles. For instance, a psychologist might identify potential resistance and go with it, rather than trying to work against it. These strategies will be discussed in more detail in Chapter 10.


Cognitive behavioural case formulation

The strengths of Persons’ approach are that (i) the mediational role of core beliefs is identified, and (ii) the treatment plan and obstacles to its implementation are linked to the formulation. The chief weaknesses are that (i) it fails to explicitly include the Consequences identified in a functional analysis and (ii) the origins are mentioned but not fully integrated into the working hypothesis. Finally, while the sequence (beginning with the problem list) might match the order in which clients present information, the sequence does not follow a theoretical order of problem development. A model of case formulation

Thus, our preference is to organize case formulation under a slightly modified set of headings: (i) Presenting problems, (ii) Predisposing factors, (iii) Precipitating variables, (iv) Perpetuating cognitions and consequences, (v) Provisional conceptualization, (vi) Prescribed interventions, and (vii) Potential problems and client strengths. In the course of the initial assessment interview(s), the psychologist will identify the main problem and any ancillary concerns (i.e., the Presenting problems), identify any experiences, social, familial or cultural issues, and temperamental factors that may set the stage for the emergence of the problem or that may influence the manifestation of the problem (i.e., Predisposing factors). The proximal and distal Precipitants of the origin problem will be identified, as well as the precipitants of the problem behaviours in the current episode. The next step will be to identify the cognitive and behavioural factors that Perpetuate the problem and then link the preceding information into a Problem conceptualization that will look backwards (and explain the origins of the problem), look around (and understand the current problem), and look forward (and make a prognosis, Prescribe treatment options, and identify Potential problems to treatment and client strengths) (see Figure 4.4). A case example

To illustrate these various components of a cognitive behavioural case formulation, an annotated case illustration will be presented next. An example of how the worksheet (Figure 4.4) can be completed follows the case example of a client with Panic disorder with agoraphobia.

Presenting problems

Therapist What’s brought you here today? Client I’ve been suffocating, all of a sudden for no reason. My doctor tells me there’s nothing wrong but she’s never done a test when it’s happening.


Linking assessment to treatment: case formulation

Figure 4.4.

Cognitive Behavioural Case Formulation Worksheet



What’s it like when you start suffocating? Well I can be sort of normal one minute and then, bang, it’s like the panic button gets pushed and I’ve just got to get out of there to get some air. I start to choke and my throat closes over like I’m going to suffocate. If I don’t get some air I’m sure I’ll pass out, die, or something like that. This lack of air is so great it’s as if you are going to die?


Cognitive behavioural case formulation



That’s right. No-one seems to understand and they all say that I’m not going to suffocate, that there is plenty of air, that my lungs are OK, but it doesn’t help. I know there’s plenty of air, but no-one seems to understand that the air isn’t getting where it should. I don’t need anyone to tell me that these problems are in my head. I can feel these sensations in my body. My heart pounds, I feel dizzy, my legs go to jelly. I even get tingling in my hands. Try to tell me that’s not a sign of suffocation! It’s a pretty serious problem to have all these signs of suffocation. I’d be quite worried if I started suffocating out of the blue. Out of the blue, that’s how it is. I’ll be walking along one minute and then my body just packs up and there’s no air.

The psychologist is starting to build up a picture of the client’s presenting problem. The problem for the psychologist is trying to balance the need to collect information on the symptoms and the need to establish a good rapport that will provide a foundation for the rest of the assessment and intervention. The client is making it clear that she feels a lack of understanding about her problems and is trying to convince the psychologist of the reality of the problems. Therefore, while additional material would be gleaned later in the interview about the problem, the psychologist has enough information to start building a profile of the problem. Specifically, the client is describing an experience that involves the sudden unexpected distressing bodily sensations (heart pounding, dizziness, choking, shortness of breath and tingling in the extremities) that the client believes, despite reassurance to the contrary, are signs of possibly life-threatening suffocation. Precipitating variables

Following a discussion of the problem, the psychologist decided that the interview would flow best if the precipitating variables were considered next. T


Thanks for telling me about how you feel during one of the suffocating episodes. I’d like to talk some more about what they are like and the effect they are having on your life a little later, but if it’s OK with you, for the time being I’d like to concentrate on what triggers the suffocation. Could you tell me about the most recent time you felt you might suffocate? I was out to dinner with some friends; a hen’s night actually. I was a bit worried that I might not feel well and have to leave. Since it was Claire’s hen’s night I felt that I really couldn’t walk out on her,


Linking assessment to treatment: case formulation




so I was extra worried. Before I got to the restaurant, I got hot and flustered because I couldn’t find a parking spot. I was driving round and around thinking, ‘‘If I don’t get a spot quickly, then I’ll be late and all the seats near the door will be gone’’. And if they were all gone? I wouldn’t be able to get out for some air without everyone noticing. And that’s just what happened. I walk in all hot and bothered only to find that the only seat left is the one at the end of the table, right down the back of the restaurant. So what did you do? I just felt like leaving right then and there, but I didn’t. I took a couple of deep big breaths and took my seat. The moment I sat down I knew it was all over. My throat tightened up and my chest started to hurt. I started to breathe faster to get some air, but the air in the restaurant was too hot. It wouldn’t get into my lungs no matter how hard I breathed  perhaps it was the spices in the cooking  but whatever it was, I knew I just had to get out. What if you didn’t get out? I’d probably pass out or die. I don’t know exactly, because I gave some excuse about having forgotten to put some money in the parking meter and I left. Just like that. I got up, walked out, and never went back. After discussing these situations the psychologist continues:



Have you always had these episodes of suffocation? When I was young I used to have asthma attacks, but they’ve stopped. Anyway, the asthma attacks were different. I can’t really describe it in words, but I know an asthma attack and these feelings of suffocation are different. They’re not wheezy, like asthma. After the asthma attacks stopped was there a time before these episodes of suffocation began? Yes, the asthma stopped in my teens and the suffocation didn’t start until my mid 20s. Was there anything going on around the time they started? It was a pretty horrible time in my life. Things were pretty stressed at work. There were lots of people being made redundant and there was a new round of redundancies in the wind. I went to a party and everyone was smoking dope. I hadn’t smoked before because of my asthma, but I figured that since it was gone I deserved a


Cognitive behavioural case formulation

bit of relaxation. The first few puffs were OK, but then I started to feel short of breath, my throat started to close up, and I started to think I was having an asthma attack. I stopped smoking and ran outside to get some fresh air. From this section of the interview you will notice that the psychologist is asking about precipitating events, but the client’s answers are blurring into the next section, namely the perpetuating cognitions and consequences. This is not a problem and your job is to use the case formulation as a template to filter and organize information. Even if you are asking about one domain and the client gives information about another, you can keep that information in mind for later. Nonetheless, a series of precipitants were evident. The psychologist covers both the precipitants of the present attacks and those of the first panic. This is important because the initial precipitants will assist the psychologist in presenting a formulation that covers both the initial onset as well as the maintenance of the problem. In terms of the current precipitants a number of elements can be gleaned from the interview. First, it is clear that the client is apprehensive about the event even before she arrives. This anticipatory anxiety is setting the stage for a panic attack. Second, building on this foundation of anticipatory anxiety is the failure to find a parking spot, which increases the worry and encourages her to rush, which in turn generates a number of bodily sensations  becoming hot and breathing rapidly. Third, upon entering the restaurant she takes a series of big deep breaths, effectively hyperventilating. Hyperventilation produces a number of bodily sensations which are able to exacerbate the sensations of panic (Andrews et al., 2003); these sensations include feelings of choking and smothering among others. Finally, the atmosphere of the restaurant appears to have exacerbated the feelings. It appears to have been hot and this could have increased feelings of discomfort given that the client was already reporting feeling hot and bothered from driving around looking for a parking spot. However, in addition to all these triggers is it clear that the client is not just a passive recipient of environmental stimuli; she is actively processing the information. Thus, the clinician can expand upon these cognitions and identify the consequences (e.g., punishment, negative reinforcement, positive reinforcement, or response cost) of any actions the client takes.

Perpetuating cognitions and consequences


You have told me about a lot of things that seemed to trigger these sensations of suffocation, but I wonder if you could tell me more


Linking assessment to treatment: case formulation








about what you were thinking. What is the last thought you remember before the feelings of suffocation were at their worst? When they were at their worst I don’t think I was thinking anything. I just go blank. What was the last thought you remember before going blank? I thought, ‘‘I’ve just got to get out’’. Why did you need to get out? I needed fresh air. I’ve found that when I’m suffocating, getting out and into the fresh air sometimes helps. What if you hadn’t been able to get out? That was what I was worried about. I was sure that I was going to run out of air. The restaurant was full of people, the door was closed, and there was an open fire in the kitchen out the back. An open fire? You know a BBQ type of thing where they were cooking the steaks. I could see the flames coming up and I know that flames use oxygen to burn. So, the fire was using up the oxygen in the room? And because the door was closed and the restaurant was full, the oxygen was getting used up. If I had been able to sit closer to the door I might have been able to get more oxygen, but being close to the kitchen meant that I had less oxygen. Had anyone else noticed the lack of oxygen? No. I think I’ve got some sort of allergy that makes me sensitive to the absence of air. I’ve read about this disease called Undine’s Curse where babies die because they aren’t sensitive to oxygen or carbon dioxide or something so they don’t breathe enough. I’ve worried I might have that, but all the doctors say my heart and lungs are fine. Does their reassurance help? For a while, but once the suffocation comes back again I think, ‘‘What do they know. If they had done their tests while I was suffocating, the readings would be different’’. You can’t remember what you were thinking when the feelings of suffocation were at their worst, but do you remember how you were feeling? Really panicky, freaked out. My heart was beating so fast and I was really scared I was going to die. And then what happened to these feelings when you left? Once I got out into the cool air, they melted away. I walked away from the restaurant and after a few minutes of letting myself breathe


Cognitive behavioural case formulation


the rich air I started to feel the oxygen flooding through me. I didn’t have to breathe so quickly and I knew that I was going to be OK. Well sort of OK. Sort of OK? Well I wasn’t going to suffocate, but then I started to think about my friends. They would all be sitting there waiting for me to come back, but there was no way I was going back. By the time I got back to the car I had tears running down my face. They were tears of relief that I had got out alive as well as tears of shame that I couldn’t even sit in a restaurant without leaving. Why can’t I be normal?

In terms of the cognitions associated with the situation, the client was interpreting the sensations as consistent with fears that she was going to suffocate. The environment was scanned to provide information (e.g., the fire was consuming the oxygen) to justify the belief that the sensations of choking and chest pain were signals of imminent death through suffocation. However, it is more plausible that the physical sensations were a normal consequence of worry and anxiety, combined with sensations generated by exertion and exacerbated by hyperventilation (Andrews et al., 2003; Page, 2002b; Taylor, 2001). It is also apparent that there was a clear contingency between the client’s actions and the intensity of the panicky feelings. After the client had fled the situation, the unpleasant experience of anxiety and panic reduced (albeit to be replaced by feelings of shame, embarrassment and distress), increasing the probability of future avoidance. Thus, their avoidance would be maintained by negative reinforcement. In addition, it is clear that the client would not be able to test the validity (or otherwise) of her beliefs about the lack of oxygen. Had she remained, she would have been able to attest to the fact that the oxygen would not have run out, she would not have suffocated and died. However, the client escaped without ever finding out if the threat would prove fatal.

Predisposing factors

So far the sections of the interview that have been reproduced do not reveal the background to the problem. Thus, to help the psychologist to contextualize the problem, it is important to consider the variables that may have predisposed the client to the attacks of panic. T

You have described some pretty terrifying experiences, all of which seem to involve intense feelings of suffocation. Feeling you are about to suffocate leads you to do the only sensible thing, which is to get


Linking assessment to treatment: case formulation



out and get to a place where there is more air. I wonder if you have thought about where this all has come from? I don’t really know, but my mother was pretty highly strung and worried about everything. When I was a child she worried a lot about my asthma. There were certainly lots of kids at school who were worse than me, but she kept insisting that we went to the doctor or emergency room to get me checked out. It seemed to make her feel better when they said I was OK. How’s you asthma now? The doctors say they can’t find a trace of it but sometimes I think I’ve taken on the role of my mother, looking after my health. You described your mother as ‘‘highly strung’’. Are you like you mother in this respect? I’ve always been a nervous person. I’ve worried about my health for as long as I can remember.

From this interaction, the psychologist was able to establish a couple of hints about predisposing variables. First, it seems it could be that the mother was high on trait anxiety or neuroticism and this family trait has passed on to her daughter, perhaps through inheritance or learning. Second, the health behaviour of her mother regarding her asthma could well have established a pattern for dealing with these sensations. That is, there is a similar pattern of concern about symptoms of suffocation, followed by an escape response that reduces the distressing emotion. Thus, the psychologist is in a position to start to develop a formulation and present this to the client for feedback.

Provisional conceptualization

In this instance, the psychologist suggested that the client’s personality was likely to reveal elevations on neuroticism, which set the stage for the development of an anxiety disorder. The experience of management of asthma attacks provided a template for health behaviour that involved worry about symptoms and escape and reassurance seeking as ways to reduce the distress associated with possible illnesses. Against this backdrop, each individual attack began with awareness of a particular bodily sensation or set of sensations (e.g., shortness of breath). These sensations were misinterpreted as signals of impending danger, which in turn triggered the anxiety (or fight or flight) response. Increased respiration, a normal part of the anxiety response, led to hyperventilation in the absence of either flight or fighting, which in turn produced more sensations. Together, these sensations would be misinterpreted as signals for suffocation, and so on


Cognitive behavioural case formulation

Figure 4.5.

Clark’s (1986) cognitive model of panic attacks (adapted from Andrews et al., 2003)

in a vicious circle of panic (see Figure 4.5). The spiral would be ultimately broken by flight, which would involve action (thereby reducing the effects of hyperventilation). What is important to note is that the formulation of the panic attack is not original to the present authors. Rather it draws on the literature about panic attacks and the seminal work of David Clark (1986) conceptualizing the panic in terms of a cognitive model. Substantial research laid an empirical foundation for the proposal of the model and subsequently much research has supported the model (see Taylor, 2001). Given this, it is not surprising that the model serves as a useful clinical heuristic. It allows the clinician to organize the information provided by the client. It permits the clinician to take short cuts by building upon the theoretical and empirical work of others. It was Isaac Newtown who said, ‘‘If I have seen further it is by standing on the shoulders of giants’’ (in a letter to Robert Hooke, February 5, 1675/1676) and professional psychologists can likewise see further in their clinical practice by standing on the shoulders of those in psychology who have synthesized clinical experience, as well as the empirical and theoretical literatures, into a clear and useful model of a clinical condition. Not every client will present in a way that so neatly fits into the textbook case. Some will include elements that are not found in models published in the literature, others will present with a blending of two or more models, and still others will present with symptoms or patterns of symptoms that appear unique. The strength of a case formulation approach is that it is applicable in every instance. What varies is the degree to which the psychologist can draw upon existing theoretical and empirical literature and clinical experiences to conceptualize the case (see Turkat & Maisto, 1985 for examples of applying case formulations to novel symptom patterns).


Linking assessment to treatment: case formulation

When the case formulation is novel, the link to treatment will need to be clearly articulated and the greater the burden of proof will be upon the psychologist to test and demonstrate the validity of the model. Even when applying an existing model to a client, it is important to test the validity of the formulation. This can be done by presenting the formulation to the client in a formal manner and asking for feedback as to its ability to consolidate the client’s problems. A further way is to test aspects of the formulation with psychometric tests (see Turkat & Maisto, 1985 for some examples). With the client in question a personality inventory (the NEO-PI-R; Costa & McCrae, 1992) was administered to determine if the trait anxiety was elevated. The SCL90-R was also administered to provide a standardized broad pre-treatment assessment that could be used to evaluate changes during and post-treatment. The results of testing are displayed in Figure 4.6. The scores for the personality dimension of Neuroticism (N) are very high, consistent with the expectations. However, interestingly conscientiousness (C) is very low. The low conscientiousness was not a theme that had emerged during the interview and suggested an area that required further investigation, particularly as it might indicate a problem for compliance with treatment. Extraversion (E), Openness (O), and Agreeableness were average. The SCL-90-R showed elevations on somatization, anxiety, and phobia which were all consistent with the reports of panic attacks. In addition, the elevation on the obsessivecompulsive, interpersonal sensitivity and depression dimensions all suggested the existence of symptoms that have not been discussed in the sections reproduced. This highlights one advantage of using broad symptom measures at the outset of treatment, in that they can

Figure 4.6.

Results on the NEO-PI-R and the SCL-90-R of a female client with Panic Disorder and Agoraphobia


Cognitive behavioural case formulation

identify areas of symptomatology that may have been ignored in the initial assessment interview(s). A verbal interpretation of these test results was presented to the client along with the formulation and the client’s response indicated that both seemed to summarize how she perceived herself. If anything, she expressed impatience and wanted to know what to do about these sensations.

Prescribed interventions

The empirically-validated interventions for panic disorder and agoraphobia have been clearly documented in many difference sources (Andrews et al., 2003; Barlow, 2002; Clark & Salkovskis, 1996; Taylor, 2000). What is involved in these treatments will be discussed in later chapters, but for present purposes, the aim is to demonstrate the link between the formulation and treatment. This is displayed in Figure 4.7. The fear elicited by the trigger stimuli will be addressed using graded exposure, the misinterpretation of these triggers as potential threats will be addressed using cognitive restructuring, hyperventilation and its effects will be targeted using breathing control, anxiety about the bodily sensations will be treated with interoceptive exposure, and excessive reactivity of the fight or flight response will be dampened down with relaxation. Thus, each important component of the model will be addressed with a particular treatment, and the rationale for each component can be demonstrated to the client with reference to the formulation. Importantly, the cognitive behavioural package that involves these components has been empirically-validated in a variety of studies,

Figure 4.7.

Adaptation of cognitive formulation to include treatments targeted at each component


Linking assessment to treatment: case formulation

lending further support to the use of these techniques (see Clum et al., 1993; Cox et al., 1992; Gould et al., 1995; Mattick et al., 1990; Taylor, 2000). In addition, there are studies demonstrating the individual efficacy of each component ¨ st & Westling, 1995; Salkovskis et al., (Ito et al., 2001; Michelson et al., 1996; O 1991; Williams & Falbo, 1996). Potential problems

The final component of a cognitive behavioural formulation involves the identification of potential problems to treatment. The low conscientiousness identified by the NEO-PI-R (Costa & McCrae, 1992) represents a possible problem in treatment, suggesting that the compliance with treatment and homework exercises will need to be monitored carefully. The second problem, which flows more directly from the formulation is the presence of worry and anxiety combined with the need for exposure to bodily sensations and situations associated with anxiety. It is likely that the client’s motivation and their impatience to begin treatment will wane as the threat of elevated anxiety and panic looms, therefore these will need to be monitored and addressed if treatment is going to be successful. The completed case formulation worksheet for this particular client is shown in Figure 4.8. This particular cognitive behavioural case formulation would represent a component of the entire clinical process outlined in Figure 4.1. As depicted in Figure 4.9, the case formulation (in the left-hand callout box) represents the link between the client data and the treatment (in the right-hand callout box).

Case formulations in interpersonal psychotherapy Up to this point the discussion of case formulation began by describing behavioural (or functional) analyses and then developed this foundation into a broader cognitive behavioural formulation. However, it would be misleading to convey the impression that case formulations are unique to CBT. The diversity of case formulations is evident in Eells (1997b), however, not all of these therapies have strong empirical validation. Therefore, we will review one more approach to case formulation to illustrate its application in the empirically supported Interpersonal Psychotherapy (IPT) and in so doing contrast the approach with a cognitive behavioural formulation for the same case. A case example

The transcript is designed to faithfully illustrate IPT as described in the treatment manual by Klerman et al. (1984). To facilitate a synthesis with their work,


Figure 4.8.

Case formulations in interpersonal psychotherapy

Example of a completed Cognitive Behavioural Case Formulation Worksheet

many of the therapist’s responses draw heavily from examples provided in their book. The client is an amalgam of individuals and draws upon a reference by Meighan et al. (1999). IPT is structured with three phases in mind. During the early phase an assessment is conducted to develop an interpersonal case formulation and


Linking assessment to treatment: case formulation

Figure 4.9.

Inclusion of a particular case formulation for a client with panic disorder into a model of clinical practice

a therapeutic contract is negotiated with the patient.1 During the middle phase the psychotherapeutic work on one or two nominated problem areas is conducted, before the termination phase occurs. There are three tasks of the early phase. These are to deal with the depression, conduct an interpersonal inventory and negotiate the therapeutic contract. Deal with the depression

IPT begins with the patient’s problem. Symptoms are systematically reviewed with reference to diagnostic criteria, such as those outlined in the ICD or DSM systems. However, the process is not one of simply reading out a checklist and ticking off each item that is endorsed. It involves asking the person about the symptoms so that you gain a feel for them. Once this is done the diagnosis is confirmed or communicated to the patient. This communication is an explicit statement that aims to make it clear that the cluster of symptoms is a whole. 1

Note that the term patient will be used in place of our term client. IPT explicitly adopts a medical model in which the therapeutic relationship is conceptualized in terms of a doctor and patient.


Case formulations in interpersonal psychotherapy

After this, is it possible to explain the nature of depression and identify ways that it can be treated. The patient is then encouraged to adopt a sick role. The psychologist is asked to legitimize the patient in the sick role without fostering dependency. Following Parsons (1951), the sick role means that the person is exempt from certain normal social obligations, certain types of responsibilities, and considered to be in a state that is socially defined as undesirable, to be gotten out of as quickly as possible. The person is in need of help and should take on the role of patient, which means affirming that one is ill and cooperating with the doctor. The possible value of medication should be assessed, which for the psychologist would involve referral; but our experience is that most people who attend our clinic with depression have already consulted a General Practitioner and been offered antidepressant medication. They have consulted a psychologist because they were reluctant to take medication, or stopped taking it due to side-effects, or the antidepressant has only been partially successful. These steps are illustrated sequentially in the following excerpts. The interview opens with an examination of the problem and a systematic review of the symptoms. The client is a male in his late 20s who has presented with concerns about his mood. Therapist I was wondering if you could tell me what brought you here today? Patient Sure. Well, it began about two years ago now, after the birth of our son, Aubrey. Things seemed to be going very well and then the wheels fell off everything. My wife became really depressed. The depression was so bad that she had to see a psychiatrist, and then spent a few weeks in hospital. Things have really gone from bad to worse for me since then and I really don’t know if I can cope any more. I think I’m catching her depression. That’s why I came to see you, but I really don’t want to be here because I should be able to cope, I should be able to keep things together. It’s my wife who is sick and if I have a breakdown, then there will be no one left to look after. I’ve got to be the stable one. I’ve got to keep the family together. T Life’s been terribly difficult for you lately, with your wife’s depression, your need to cope with everything that her being depressed entails, and starting to feel depressed yourself. We’ll talk about each of these topics, but first of all, I wonder if we could talk about you and how you are feeling. I wonder if you could tell me something about these feelings of depression. P Well, I just feel empty all the time. I’m just like a hollow shell just doing the same things each day that I have to do, but there’s no life left in me. I can’t get out of bed in the morning, not only because I’m


Linking assessment to treatment: case formulation




so tired due to not being able to go to sleep, but because I just haven’t got any energy. I try to get myself motivated, but nothing appeals any more. I used to play golf, but I’ve given that up; and sex, well there’s nothing in that department. I know they say that having a child is the most effective form of contraception known to man, but she’s not up for it and quite frankly I could take it or leave it; and this is not like me at all. Eating too  I’ve lost 7 kg in the past month because I can’t seem to bring myself to eat. Food tastes bland and I just don’t feel hungry. These feelings seem to impact everything you do. Has this depression had an impact on your life; say looking after Aubrey or at work? I’ve just received my second warning from my boss at work. I’m just not able to concentrate at work, so I keep making mistakes. Also, every couple of weeks I get a call from Suzanne, that’s my wife, saying that she can’t cope with Aubrey and I need to come home to rescue her before she does someone an injury. I’m just in a bind, I can’t afford another mistake at work, but at the same time I worry that something bad will happen at home. Often when people feel as depressed as you have been telling me you feel, they think about ending it all. Have you thought about killing yourself? Everyday. Usually as the day goes on I think about it more often, but I’d never do it. I’m all that there is holding the family together right now.

The therapist then moves on to confirm the diagnosis to the patient. The name of the disorder (in this case depression) is used. The use of the name is intended to organize what otherwise might be a group of seemingly unrelated symptoms into a condition that the psychologist knows about. T

The feelings of depression, the lethargy, the lack of interest in previously pleasurable activities, the difficulties sleeping are all symptoms of depression. Although they don’t seem to have a physical basis, this isn’t to say that they aren’t real. What you have told me are pieces to a puzzle, that when put together suggests to me these are all part of being depressed. Your eating and sleep are changed. You’ve lost interest in activities that you used to enjoy. Your thoughts about death, your tiredness, . . . are all part of the constellation of depression. Your symptoms are common ones for depressed persons.


Case formulations in interpersonal psychotherapy


So you really think I have depression? What am I going to do? When it was just Suzanne, that was bad enough, how are we going to manage?

The psychologist can respond to this question by leading in to a presentation of details about depression and its treatment. T


Depression has been called the common cold of mental disorders because it is so common. It affects about four out of every hundred adults at any one time. Although you may feel a lot of hopelessness right now, this is part of depression and the good news is that depression can respond to treatment. The outlook for your recovery is good. We know there are quite a few treatments that can reduce depression so many people with depression recover quite quickly with treatment. I expect that you will soon start to feel better and you will be able to resume your normal life and activities as the symptoms of depression decrease in response to treatment. One effective treatment for depression is Interpersonal Psychotherapy. It has been shown to be effective in a number of research trials. IPT helps you to understand the issues and difficulties that have produced this depression. Well I’m glad that you’re hopeful, because quite frankly I’ve lost all hope. Life’s just all too much for me right now. In fact, I can’t even face up to having the parents-in-law over for dinner. The next task for the therapist in IPT is to outline the sick role to the patient.



It’s fine if you don’t feel like being quite as sociable now. You are feeling depressed and so its quite reasonable that since you are feeling so bad you won’t be able to do many things you might feel you should. Perhaps you could speak to Suzanne and suggest that for the next month you’d like to keep social obligations to a minimum. The reason is that during the active phase of treatment for your depression we are going to be working towards your recovery. I expect you to be able to take up your normal life gradually. You will be able to become more active again, but for the time being the focus needs to be on getting you better. Can I tell Suzanne that you said this? I wouldn’t want her to get the impression that I’m not handling everything. I’ve got to hold this family together. The way things are right now, I can’t be the weak link.


Linking assessment to treatment: case formulation


Yes you can, it’s important that you talk with her and make sure that she is clear that you are going to need some time right now to work on yourself so that you are in a stronger position to help her.

For many psychologists, casting the patient in the sick role elicits a negative reaction. As a profession we are more likely to consider that clients need to take an active role in their recovery. In particular, psychologists who are expert at CBT will be familiar with the need to recruit and sustain motivation during treatment (Miller & Rollnick, 2002) and the importance of a collaborative relationship that includes homework activities. The notion that the patient is sick may feel like the psychologist is fostering dependency. These points are welltaken, but take a moment to reflect on the experience of being depressed. The sufferer may have been struggling with their daily tasks and to the extent that they have not completed these, they may have felt a failure to meet the real or projected expectations of others or themselves and the consequential guilt. Being instructed that treatment not only permits, but actually requires them and others to take things a bit easier could well make the person feel some relief from guilt and unattainable expectations. This is not to say that the psychologist should not consider the risks of fostering dependency, but that these risks need to be weighed up in light of the potential benefits.

Assess the interpersonal problems

Once the presenting problem has been addressed the interview moves to assess the interpersonal problems, and this begins with an Interpersonal Inventory. The psychologist asks questions to elicit information about what has been going on in the patient’s present (or past) social and interpersonal life that is associated with the onset of the symptoms. Thus, the interview will focus upon important interactions, expectations of everyone in these important relationships, and the degree to which they are met. The satisfactory and unsatisfactory aspects of relationships are reviewed and the patient could be asked to identify ways they would like to change their relationships. The ultimate aim is to identify the main problem area or areas. Within an IPT framework there are four problem areas, which we prefer to summarize under the two headings of Loss and Growth and Interpersonal Communication. Under the heading of Loss and Growth, IPT identifies grief reactions (associated with the loss of a loved one) and role transitions. In a role transition the person loses past relationships and must grow into a new role and new relationships or ways of relating as they move from one stage of life to another (e.g., work to retirement, partner to parent, employee to manager, etc). Under the heading of Interpersonal Communication IPT


Case formulations in interpersonal psychotherapy

identifies interpersonal role disputes (in which people in a relationship have unshared or unmet expectations) or interpersonal deficits. T



Now, let’s try to review what has been going on in your life. What else has been happening in your life about the time you started feeling bad? As I said earlier, it seems that everything has happened since the birth of my son. Before Aubrey was born Suzanne seemed normal, and we had a great relationship. She seems to think that she was depressed, but I wasn’t aware of anything. Things seem to have changed after the birth. I was so looking forward to our future together as a family. I had just got the promotion at work I’d been striving for, we now had the money to have a child and really give him the life that we wanted. But all that has changed. Before the birth, Suzanne was all clucky and maternal, but now she’s so different. I’ve not seen that side of her before.

The patient is describing a role transition (from being a partner to being a parent), but what is also apparent, that the patient is describing a loss. The patient is lamenting the loss of the previous relationship as well as the loss of the relationship that could have been. Both of these themes emerge during grief work, and for these reasons we tend to group the categories of grief and role transition under the same heading. T P



What is this side that you haven’t seen before? I’d get home and there she is holding the screaming baby. She hands me the baby and starts crying and screaming at me, blaming me for doing this to her. Then she collapses in tears saying she didn’t mean it and she feels so guilty. All I know is that at one moment there was a crying baby to care for, then there was a crying wife to care for, and all I felt like doing was crying myself. The problem is there is no-one to pass the baby to  the buck stops with me. This seems like an incredible burden for you to carry. I just wished I knew what to do. If she was a car I would have lifted up the bonnet, found the problem, fixed it and that would be the end to it, but nothing I did made any difference. This was the hardest thing to cope with  knowing that I couldn’t fix it. You felt hopeless even though you wanted to help your wife. All I could do was hunker down for the duration. It was up to me to hold things together so I had to take care of them, no matter what


Linking assessment to treatment: case formulation





the cost. I hate the way things are at work, but if that’s what I’ve got to do, then that’s what I’ll do. Do you take that hunker down attitude home with you too? I guess I’ll do whatever it takes to get through this. I’ve tried to keep the peace at home. I had to sacrifice my own feelings. I didn’t want Aubrey to be damaged by all this so I just put my feelings on hold. This must have taken its toll on you. I just feel so exhausted. I would get so tired doing my job at work and then coming home to another one when I got home. I’m on duty 24 hours a day, 7 days a week and all the time dreading the call from home when she’d say, ‘‘you’ve got to come home, I can’t take it another minute’’. It sounds like it took a toll on your relationship too. There’s no relationship between us anymore. We are just living day by day. It’s like I’ve lost her and she’s not even gone away. I’m learning that things have changed. There’s nothing I can do to make her happy and I can’t make myself happy now either. What sort of things used to make you happy? Work used to be my best source of happiness, but things have changed there. How have they changed? The promotion has changed everything. I used to just be able to do my job, but now I’m in charge of the whole purchasing department. I used to have heaps of friends at work, but now I don’t know who my friends are. Sometimes I need to reprimand people who used to be my mates, and other people who never used to speak to me seem to crawl to me all the time. I just hate it and wish I could have my old job back. The problem is I’m trapped, because we need the extra money now we’ve got the baby.

It appears that the patient is describing some ways of relating that might suggest interpersonal skill deficits. That is, the person’s way of relating in past relationships appeared effective, but in the new relationship there could well be behaviours that are not in the patient’s repertoire (e.g., reprimanding colleagues, assigning tasks, conducting performance reviews, etc.). A more detailed analysis of these situations could reveal the absence of certain interpersonal deficits that need to be redressed. T

Has work changed anything apart from you friendships?


Case formulations in interpersonal psychotherapy


I used to be really comfortable with my work. I knew my job and I knew that I could do it. Now everything’s changed. I don’t know what my job is anymore and I don’t know if I can do it. My selfesteem has gone through the floor because I’m no longer confident that I’m succeeding.

The psychologist then moves to summarize this part of the interview and starts to draw out some interpersonal patterns. Although the two role transitions are different, there are common elements that suggest some recurring patterns that could well benefit from being addressed within the course of subsequent IPT sessions. T

It seems from what you have been telling me that you have been having trouble in your marriage since the birth of your son and at work following your promotion. The problems can certainly lead to depression. I’d like to meet with you over the next few weeks, for about an hour each time, to see if we can figure out how you can cope better with the situation.

Negotiate a therapeutic contract

Finally, the psychologist and patient negotiate a mutually agreeable therapeutic contract. This involves explaining the role that interpersonal factors may play in depression. Patients are informed that they will be responsible for deciding on the focus of treatment, bringing new material, and choosing the topics to discuss. Following this, two or three treatment goals are set. These goals need to be potentially achievable within the time frame of therapy and may be symptomrelated or interpersonal. P T

But what is causing this depression? We live in a social world and we are social beings. People play a significant part in our lives. When depressed we are inclined to think we are alone, but we remain social beings. It is not surprising then that relationships play an important role in depression. So far we don’t know all the causes of depression, but what is clear is that when you are feeling depressed you tend also to be having problems with personal relationships. These problems in relationships could include issues with your partner, children, family or work colleagues. Sometimes relationship problems or bereavement may bring on depression. At other times, or with other people, being depressed may stop them from dealing with other people as well as they would like


Linking assessment to treatment: case formulation




(and used to). We will try to find out what you want and need from others and help you learn how to get it. We will try to understand how your relationships are related to your depression. How long are we going to do this for? My preference would be for us to meet once a week for about 16 more sessions. During this time we will work to understand how your relationships are related to your depression. Okay, but what will we do? From what you tell me, your depression began with recent transitions. One of the transitions was the birth of your son and your wife’s depression, the other was your promotion at work. I’d like to discuss with you the critical areas you seem to describe as related to your depression. One is the kind of transition you’ve had to make from being a worker to a manager. The second issue centres on how you are relating to your wife, the impact of her depression on you and how you are acting in this relationship. Do these sound like the issues we should work on? Sure.

Summary and contrast with CBT

In the preceding discussion and case example, the key aspects of an IPT formulation have been clarified. In the early phase of IPT the psychologist will deal with the depression, assess the interpersonal problems, and negotiate a therapeutic contract. To date there is little additional documentation in the IPT literature of the details of case formulation or psychometric assessments to identify which of the four interpersonal areas (i.e., role disputes, grief, interpersonal deficits or role transitions) are present and warrant treatment (although see Markowitz and Swartz, 1997). A case formulation from a CBT perspective will share many similarities with an IPT approach. However, the emphasis and treatment plan would be different. Therefore, let us consider how the preceding case might be conceptualized from a CBT perspective. Under the heading of Presenting Problems would come the list of symptoms of depression that the client described. At this point there would be no difference between CBT and IPT case formulations. In terms of predisposing factors, little attention was paid to predisposing factors and therefore minimal information is available in the IPT formulation. This highlights an important point, which is that the framework within which the case formulation is conducted has the capacity to influence the information elicited from the client. Considering the


Case formulations in interpersonal psychotherapy

Precipitating variables, there appear to be a variety of factors. These precipitants include the birth of his son, the promotion at work, his wife’s onset of depression (and the impact and stress that this is having upon the relationship, his work, and so on). Once again, these are factors that would be drawn out within an IPT framework. One important difference arises when the Perpetuating cognitions and consequences are considered. The client describes quite a number of themes that would be relevant within CBT. For example, he comments, ‘‘I should be able to keep things together. It’s my wife who is sick and if I have a breakdown, then there will be no one left to look after. I’ve got to be the stable one. I’ve got to keep the family together’’. It is evident from these sentences that the client is identifying expectations that he has about himself that will be counterproductive and likely to enhance feelings of hopelessness, a lack of coping, and stress. In addition to these and other cognitions a CBT therapist would consider the consequences of his behaviours. Two patterns are evident. First, it is apparent that positive reinforcement is lacking and punishment occurs regardless of his responses, both at home and at work. That is, unpleasant consequences seem to arise whatever he does. The lack of sufficient positive reinforcement has been identified as an associate of depression (Lewsinsohn & Graf, 1973) and so too has the occurrence of aversive stimulation that is not contingent upon any responses a person might give (Seligman, 1975). Putting this together, a provisional conceptualization might be that the client had certain beliefs about his role as a father (e.g., being the one to hold things together) and his wife’s role as a future mother (e.g., she could be maternal and clucky), as well as expectations about his promotion. In each of these scenarios, the expectations he had of himself and others were not met. He did not modify these expectations and thus became depressed as he felt increasingly unable to control his negative emotional reactions and his inability to control his home and work life so that it met his expected ideal. Thus, a Prescribed intervention might involve behavioural activation to reinstate previously pleasurable activities, moving to identify the links between actions and moods and cognitions and mood. Cognitive therapy might then be used to modify the unhelpful cognitive patterns and behaviour management strategies implemented. Finally, some Potential problems in treatment might be his wife’s depression as well as his hunker down attitude, which might lead to a reluctance to become involved in treatment and wait for it all to blow over. In summary, case formulation is a process of obtaining and organizing data about a client’s problem into a format that guides treatment. Case formulation has been illustrated in the context of cognitive, behavioural and interpersonal interventions for various psychological problems. However, case formulation is not unique to these approaches to psychological problems and Eells’ (1997b)


Linking assessment to treatment: case formulation

book is a good source to develop an appreciation of the diversity of approaches to case formulation. In routine clinical practice, case formulation will be relevant with every client. However, it will be most straightforward when client’s problems conform to the mythical textbook case, in which the disorder is welldocumented and the treatment well-validated. For instance, in Fairburn’s (1995) treatment manual for bulimia, case formulation is used to help the psychologist decide in which order to present the empirically-validated treatment modules (see Wilson, 1996a, b for a discussion). Therefore, the topics for consideration in the next chapter are some of the available psychological treatments.


Treating clients

Much effort has been expended trying to partition the variance attributable to the specifics and non-specifics of therapy. However, for a practitioner the specifics of a therapy are invariably delivered in the context of a therapeutic relationship. Clinical psychologists generally consult with clients in person, be this individually or in groups. In Chapter 2 we considered some of the important aspects of the therapeutic relationship but in the present chapter we will turn to some of the specific psychotherapeutic techniques that have empirical support. As evident from the model in Figure 5.1, treatment planning follows from a careful assessment and formulation of the client’s problems. The selection of treatment involves a considered and critical evaluation of the empirical literature. Although this consideration also draws upon clinical training and experience, published literature has passed through a peer review process and hence deserves greater weighting in the selection process. One recent review of the psychotherapy literature has been provided in A guide to treatments that work edited by Nathan and Gorman (2002; see also Roth & Fonagy, 2004). The process adopted in this review was that criteria for standards of proof were established and then the available literature was summarized in a way that the quality of the empirical support for the treatment of each disorder could be coded. The strongest support came from Type One Studies which used a randomized, prospective clinical trial. To qualify at this high level, the study needed to involve random assignment to conditions, blind assessments, clear exclusion and inclusion criteria, sound diagnosis, adequate sample sizes, and clear and appropriate statistical methods. Type Two Studies were similar to Type One Studies, except that some aspects were absent (e.g., non-random assignment). Weaker empirical support again was taken from Type Three Studies, which were open treatment studies and case-control studies collecting retrospective information. Type Four Studies were those that involved secondary data analysis (e.g., meta-analysis). Type Five Studies were reviews without secondary data analysis and Type Six Studies included case studies, essays and opinion papers.


Treating clients

Figure 5.1.

A science-informed model of treatment selection

Clearly any interpretations based on reviews such as the one reported by Nathan and Gorman (2002) are open to allegations of being incomplete and potentially biased. For example, conclusions can only refer to treatments that have a broad research base and the review will omit newer treatments (e.g., Emotion-Focused Therapy; Elliott et al., 2004) or those that may be effective but have not been well-researched to date. The conclusions may be biased because some psychotherapies might not lend themselves as readily to empirical evaluation according to the specified criteria; the treatments included may be ones that emphasize efficacy over effectiveness, focus on ICD and DSM diagnoses, and some procedures (e.g., in vivo exposure for specific phobias) may suffer from the bulk of the research being conducted during times when the criteria for conducting and reporting outcome research were less stringent. However, while a scientist-practitioner must always recognize the limitations of any data set upon which interpretations are based, critical evaluation must acknowledge that the products of a systematic review place individual practitioners in a strong position to lay empirical foundations for the practice of clinical psychology. In comparison to the state of the empirical foundation of clinical psychology when Hans Eysenck (1952) claimed that psychotherapy


Behaviour therapy

was no more effective than spontaneous remission, it is now possible to identify some broad areas where psychotherapy is efficacious. This is the nature of science. Our conclusions will always be tentative, more and better data available tomorrow will alter the inferences we would draw today, but scientistpractitioners must allow their treatment decisions to be influenced by a careful appraisal of the best data currently available. When examining the conclusions of Nathan and Gorman (2002), it is clear that psychological and pharmacological treatments can alleviate a wide array of psychological problems. Focusing on the psychotherapies, Behavioural (including variants such as Dialectical behaviour therapy; DBT) and Cognitivebehavioural therapies (CBT) have fair to strong empirical support in the treatment of Attention deficit hyperactivity disorder, Alcohol use disorders, Avoidant personality disorder, Body dysmorphic disorder, Borderline personality disorder, Bulimia nervosa, Conduct disorder, Conduct disorders, Depression, Generalized anxiety disorder, Hypochondriasis, Obsessive-compulsive disorder, Paraphilias, Panic disorder (with and without Agoraphobia), Post traumatic stress disorder, Schizophrenia, Sleep disorders, Social phobia, Somatoform pain disorder, and Specific phobias. Interpersonal psychotherapy (IPT) has a demonstrated efficacy only for depression, and Dynamic/psychoanalytic psychotherapy has some support in the treatment of Borderline personality disorder and other Personality disorders. Thus, when making decisions about the direction of treatment, a clinical psychologist will need to be cognizant of the relevant empirical literature to best inform these decisions. The remainder of this chapter will introduce some elementary components of these empiricallysupported treatments, but more detailed presentations can be found in the books listed in the Useful Resources at the end of this book. Further, since many techniques are modified for application in many different clinical problems and psychological disorders, we will concentrate on providing a description of particular procedures that are broadly applicable.

Behaviour therapy In contemporary clinical practice behaviour therapy is often delivered alongside cognitive interventions, but for didactic purposes it is useful to consider them separately. The theoretical underpinnings of behaviour therapy have a long tradition (Pavlov 1927; Watson, 1924) but recent learning theory emphasizes contingency over contiguity (Rescorla, 1988; Rapee, 1991). That is, the important relationships are those in which there is a contingency between two events, rather than a temporal contiguity between a stimulus and a response. Thus, in contrast


Treating clients

to its early roots, behaviour therapy is much more cognitive and learning theory emphasizes the learning of relations between events (if X then Y learning). Consequently, the aim of behavioural interventions is to modify learning by changing the parameters that control the acquisition of the if X then Y rules. Broadly speaking, there are two approaches to modify behaviours. First, we can attempt to modify behaviours by managing the contingencies that control the behaviour. Second, we can attempt to modify behaviours by training the client in self-control strategies. Let us consider contingency management first. Contingency management

Contingency management refers to the presentation of reinforcers and punishers in a contingent manner where the goal is to manage or modify behaviour. Learning theory assumes that there are general laws that govern the effects of different contingencies but it also acknowledges that due to the variability in learning histories, clinical practice must take into consideration the unique aspects of each individual. It is necessary to measure every intervention and monitor throughout the treatment process to ensure that the laws are in operation. Treatment begins, therefore, with a baseline measurement against which changes can be measured and monitored. Reminiscent of the methods of case formulation, these ratings will be direct measures of the behaviour in question, its antecedents and its consequences. In considering what to measure and how to intervene, one of the first questions is, ‘‘What is a reinforcer?’’ This is an important theoretical issue with clear clinical implications. The Skinnerian definition states that a reinforcer is anything that changes the frequency of a behaviour if it is applied contingent upon emission of that behaviour. This suggests that identifying a reinforcer is an empirical question; you just have to try them out until you find what works. In clinical practice this would lead you to consult lists of possible reinforcements or speak with clients (or a person speaking on the client’s behalf) and ask them to rate the reinforcing value of the alternatives. A second definition comes from the work of Premack (1959) and avoids the apparent circularity in the Skinnerian definition. Premack’s principle is that given two responses, the more probable will reinforce the less probable and not vice versa. Premack’s principle implies that to isolate a reinforcer, you just have to identify a behaviour with greater probability than the behaviour in question, and then make the target behaviour contingent upon the high probability behaviour. For instance, Flavell (1977) sought to increase studying, so looked for a behaviour with a higher frequency than studying (in this case, showering), and made showering contingent upon studying. The effect was studying increased. In this example, you could argue


Behaviour therapy

that showering was more pleasant than studying, but according to Premack’s principle, the key is not the pleasantness but the natural frequency of a behaviour. Independent of definition, reinforcers are generally divided into primary (i.e., those which satisfy an innate, biological need; e.g., food) or secondary (i.e., conditioned, e.g., money) reinforcers.

Increasing desired behaviours

Positive reinforcement (sometimes called reward) seeks to increase the likelihood of a desired response by applying a reinforcer contingent upon the desired behaviour. When doing so, it is recommended that once a target behaviour has been selected as needing to be increased in frequency or intensity, you deliver the reinforcement immediately after a target behaviour and that you do so contingently and consistently. You may need to vary reinforcers to avoid loss of potency, and while you reinforce often to begin with, it is important to fade out and allow the natural reinforcement to take over. For this reason it is also desirable to use social reinforcement whenever possible as you fade out primary reinforcers to ensure that they are replaced with social reinforcement. For example, to increase peer interaction, you might use a star chart with primary reinforcers to reinforce social contact with peers, but then ensure that the inherent reinforcement from social interactions are brought to bear as the primary reinforcers are faded out. Another method of fading out is to use a pyramid chart in which the number of behaviours (i.e., stars on a chart) required to obtain a primary reinforcer increase in a linear manner so that as time goes on, the reinforcers become more sparse. Another way to increase desired behaviours is to use negative reinforcement. Negative reinforcement is not punishment (which decreases undesirable behaviours), but negative reinforcement involves removing a reinforcer contingent upon some behaviour, which in turn increases the likelihood of that behaviour being emitted in the future (e.g., a client with tension headaches who finds that using a newly learned relaxation technique successfully alleviates the headaches, will be more likely to use relaxation exercises in the future). Similar to positive reinforcement, the termination of the reinforcer should follow immediately, contingently and consistently after the behaviour. The time between trials must not be too brief otherwise the offset of the reinforcer (e.g., the relief ) is not of sufficient intensity or duration. If there is no progress, you might need to check that the aversive experience that is being terminated is aversive to the person in question or you may move to avoidance conditioning (i.e., emission of a behaviour avoids the presentation of a stimulus).


Treating clients

Decreasing problem behaviours

Contingent punishment describes any procedure that decreases the future probability of a response being emitted. It is important to note that just because something is aversive, it does not mean that it is a punisher. For instance, yelling at a child may be aversive, but it may be positively reinforcing because of the attention that the child is receiving. There are two problems with using punishment. One is that in the past it has often involved physical punishments, which often are not socially acceptable or legally permitted. The other problem is that while punishment decreases behaviours it does not facilitate desirable behaviours. Thus, if punishment is used, then it needs to be used in conjunction with positive reinforcement of desirable behaviour. As with all behaviour management processes, but particularly in the case of punishment, it is useful to inform the client of the contingency. The punisher should be immediate, contingent and on a continuous schedule with a duration and intensity that is minimal enough to be effective and a plan to promote generalization of any learning. For example, the bell and pad (Lovibond, 1964; Mowrer & Mowrer, 1938) is an arrangement to treat nocturnal enuresis in which the bed-wetting is reduced by an alarm triggered by the presence of a liquid-sensitive alarm placed beneath the sheet. The alarm needs to be sufficiently loud to wake the child during urination from sleep and therefore, the intensity of the alarm is not to punish in the conventional sense of the word and there is no need for it to be aversive. Rather, the aim is to rouse the child from sleep and permit learning of the cues that signal nocturnal urination. However, it meets the technical definition of a punisher, in that the onset of the alarm is associated with a decline in the frequency of an undesired behaviour. Another method of reducing undesired behaviours is to use time out from reinforcement. Time out from reinforcement (and response cost) are sometimes distinguished from response-contingent punishment by calling them negative punishment and the contingent punishment positive punishment. Time-out from reinforcement describes a period in which previously available positive reinforcement is unavailable. It is useful to use the full title, rather than the abbreviated time out because it will help you remember what the necessary conditions are. Namely, there needs to be an ongoing schedule of positive reinforcement and the person needs to be removed from the environment where the positive reinforcement is ongoing at least for long enough to have missed out on one reinforcer. Many discussions arise because people forget that it is time out from reinforcement. For instance, parents may send children to their rooms but find this is ineffective because they like being there. Another signal that you have forgotten the nature of the procedure is if you start to identify the optimal duration of time out with respect to a clock rather than with reference to the


Behaviour therapy

schedule of reinforcement that the person is being removed from. It also indicates that if a person is a reinforcer, removal of the person (rather than the client) for a specified period of time (e.g., a mother ignoring a child and going off to read a magazine) may also be effective. As with punishment, time out from reinforcement needs to be used in conjunction with reward of desired behaviours. It is useful to identify a time out area that is safe and free of reinforcement. Shorter durations are preferred because while the person is in time out from reinforcement they are often removed from learning opportunities. Undesirable behaviours can also be reduced with response cost and extinction. Response cost involves a previously acquired reinforcer being forfeited contingent upon the emission of an undesired response (e.g., removing marks for a late assignment). Response cost needs to be used in conjunction with positive reinforcers (to increase desirable behaviours). It requires the clinician to identify an effective reinforcer to be lost, the magnitude of which is commensurate with the undesirable behaviour. It needs to be instituted immediately after behaviour which can later be brought under verbal control. Extinction involves the cessation of reinforcement of a previously reinforced behaviour. It is important to note that extinction is not unlearning, but is the learning of a new contingency. Once extinction has occurred, the person has two If X then Y rules, but one is given more weight. Remembering this aspect of learning theory helps you to expect four phenomena that regularly occur in clinical practice. First, there is reinstatement of the response. As the Rescorla & Wagner (1972) model predicts, learning can be reinstated by the presentation of the Conditioner Stimulus (CS) or the Unconditioned Stimulus (US). Therefore, experience of the US may reinstate old learning. For instance, once a phobia has been extinguished, the occurrence of fear may be sufficient to reinstate fears (Jacobs & Nadel, 1985; Menzies & Clarke, 1994, 1995). Second, changing the context can lead to renewal of responding. Bouton (1991) has outlined this in detail, extinction is context specific and therefore, once you change contexts, the learning that you have achieved may be lost. Contexts can be locations, but they can also be interoceptive (e.g., a drug-induced state), temporal (passage of time), and so on. A third factor is re-acquisition, such that previously extinguished behaviours are much more rapidly learned. For instance, tolerance is more rapidly acquired following each period of detoxification. Finally, there is rebound (extinction burst). That is, when you put a behaviour onto an extinction schedule, there is an increase in the behaviour (e.g., tantrums). Satiation is another way to reduce the undesirable behaviours. Reinforcers lose their reinforcing qualities over time. This may be a danger when trying to


Treating clients

increase one response, but it is useful when trying to decrease another. The essence is to use continual exposure to a reinforcer, so that it loses its reinforcing qualities. In practice, there are a number of potential problems. First, the reinforcer must be identified and able to be provided in sufficient quantity (e.g., Allyon (1963) took 635 towels to satiate a client’s hoarding of towels!). Second, reinforcers may be harmful in high doses or frequencies. Third, some reinforcers may not be accessible to satiation (e.g., social reinforcement). Two other ways to reduce undesirable behaviours are positive practice and overcorrection. Positive practice involves reducing unwanted behaviours by encouraging the repeated practice of adaptive or desired behaviours. Overcorrection involves two components; restitution and positive practice. Restitution requires that the environmental disruption of the undesirable behaviour is restored and the positive practice component involves restoring the environment to a better state than before. An example might be being asked to clean up the entire playground after dropping a single piece of paper.

Differential reinforcement

Sometimes, the goal of a behaviour modification strategy is the increase or decrease in rate or frequency, rather than just the absence or presence of a behaviour (e.g., eye contact). Therefore, rates of behaviour can be differentially reinforced in a variety of ways. Differential reinforcement of low rates (DRL) of behaviour encourages slow responding. Behaviours are reinforced only when they occur after a certain amount of time after the last response. Differential reinforcement of high rates (DRH) of behaviour encourages rapid responding. Behaviours are reinforced only when they occur after a short amount of time after the last response. As discussed earlier, one problem with punishment, response cost and time out is that they do not encourage new and more productive behaviours. To overcome this weakness, differential reinforcement of other (DRO) behaviour can be used. Rather than punishing one response, or in addition to punishing a response, some other response is reinforced. For instance, you may choose to ignore rudeness in a child (e.g., putting the behaviour on an extinction schedule if attention was maintaining it) and attend to constructive play. A related schedule is the differential reinforcement of incompatible (DRI) behaviours. That is, another behaviour is chosen to reinforce and the selection is based upon the fact that it is incompatible with the undesired behaviour. For example, hand or finger waving in a child with autism may be punished (with contingent delivery of smelling salts) and then followed by rewarding constructive manual play.


Behaviour therapy

Contingency contracting

The presentation so far may have given the impression that behaviour therapy is a technology that is applied to a client, rather than involving a collaborative relationship. While it is true that contingencies can be effectively applied to unwilling clients (e.g., random breath testing), behaviour therapy can be delivered in a collaborative relationship. Contingency contracting is one way to achieve this end. Contingency contracting involves clearly specifying in advance the nature of the contingencies now in operation. Research indicates that the most effective contracts are those that specify the treatment strategies and the expected outcomes. Further, efficacy is increased if the contract elicits from the client an agreement to participate fully in the programme. One common form of contingency contracting is an interpersonal one. Two individuals agree to reciprocal rules such as, ‘‘if you do this, then I’ll do that’’. Another common form of contract is the deposit contingency, in which a deposit is forfeited if a behaviour is not emitted (e.g., lose deposit if therapy is prematurely discontinued). Habit reversal

Behaviour therapy techniques can be combined as required. An example of such a combination is a procedure called habit reversal. Developed by Azrin and Nunn (1973) it involves the practice of behaviours that are incompatible with or opposite to the habit in question. For instance, nail biting may be treated by practicing hand clenching. The components of treatment are (i) self-monitoring in which the behaviours are identified, (ii) habit control motivation in which the clinician reviews the inconveniences of the undesirable behaviour, (iii) awareness training, in which the normally automatic and habitual sequence of behaviour is brought into conscious awareness, (iv) competing response training, where the client practices a behaviour incompatible with the habitual behaviour, (v) relaxation training and (vi) generalization training in which high risk situations are identified and contingency plans are organized and practiced (see Stanley & Mouton, 1996). Variables that influence performance

Although operant procedures do not require the use of language, providing information and negotiating contracts will facilitate the process. It is also important to consider the variables that can affect performance. Subject variables that can affect performance include motivation and learning to learn. One example of subject variables can be seen in Azrin and Foxx’s (1974) dry bed training. The treatment begins by encouraging the child to drink as much fluid as possible in order to create the environment for learning. Another example is


Treating clients

learning to learn. This describes the observation that learning is faster the second time around. Harlow (1949) discovered the phenomenon when he observed that monkeys were faster solving a novel problem after they had experience with a previous (but different) problem. In the words of Harlow, people acquire a learning set, a way of acquiring knowledge. Thus, a clinical implication of this is to identify not only a person’s past learning, but try to identify their learning set (i.e., what sorts of ways have they learned in the past). You can then teach the new behaviour in the way that previous learning was acquired. Another class of variables that influence performance are response variables. First, there is belongingness. Deriving from the work of Garcia and Koelling (1966), we know that certain stimuli are conditioned more readily to certain responses. This can be applied by framing the intervention in terms of the natural tendencies. The third class of variables that influence performance are schedules of reinforcement. One of the simplest parameters is delay of reinforcement. The shorter the delay between the response and the reinforcer, the greater the probability of learning. Another parameter is the reliability with which the reinforcer follows the behaviour. Continuous reinforcement produces rapid learning, but extinction is more rapid than with partial reinforcement. Therefore, training usually begins with continuous reinforcement and moves to partial reinforcement. Note also that partial reinforcement produces the partial reinforcement extinction effect (that is, responding continues for a long time after extinction when responding has been partially reinforced). The number of responses required for a response is also important to consider. Ratios may be fixed or variable. Ratios produce a scallop (with a post-reinforcement pause and a ratio run), except that if the number of responses required is too great (i.e., the ratio strain is too high), responding will stop altogether. Instead of reinforcing number of responses, you can reinforce responses that are emitted after a certain period of time. Once again, the interval schedules may be fixed or variable. In clinical practice, two points to bear in mind are, first, variable schedules of reinforcement produce more steady rates of responding than fixed rates, and second, ratio schedules are extremely motivating because the person is encouraged to respond at higher rates. Introducing new behaviours

Sometimes the aim is not to increase a desirable behaviour but to introduce a new behaviour or set of behaviours to an individual’s repertoire. For instance, desired behaviour may not appear in its complete form during the early stages of a programme. One strategy to introduce new behaviours is to use shaping and reward successive approximations. That is, the clinical psychologist reinforces


Behaviour therapy

behaviour that approximates the desired behaviour, but as time goes on, the rules for reinforcement become more stringent and the requirements move towards reinforcing behaviour that more closely approximates the desired behaviour. When using shaping, it is recommended to identify a high frequency behaviour similar to the target behaviour and then establish a criterion for first approximation (low). After this, the clinician will arrange the context to maximize the probability of a response occurring and then differentially reinforce variants of the desired behaviour and withdraw reinforcement from behaviours incompatible with the desired behaviour. Over time the clinician will shift the criterion for reinforcement as there are shifts in topography of the behaviour towards the desired behaviour. Sometimes verbal or gestural prompts may be used to guide and encourage approximations of the target behaviour. Prompting is useful in the initial stages of a training programme. A cue is delivered, that initiates the response, so that the response can be reinforced. Another strategy to introduce new behaviours is chaining. If complex behaviours (e.g., tying shoe laces) are to be trained, often shaping will not work because the behaviour will not occur even with prompting. Therefore, chaining can be used if the behaviour can be broken down into a series of elements that need to be performed sequentially. The behaviour is broken down and each element is reinforced either beginning with the first of last behaviour in the sequence. Forward chaining is when the reinforcement begins with the first behaviour in the sequence (e.g., brushing teeth). Backward chaining is when the reinforcement begins with the last behaviour in the sequence (e.g., tying shoe laces). Maintenance of behaviours

The main problem with contingency management is that of stopping the contingency but maintaining the desired behaviour. One way of solving this is to ensure that the behaviour soon comes under the reinforcement of natural contingencies. For instance, reinforcing peer play may soon be unnecessary if peer interactions become inherently rewarding. However, thought needs to be given to fading out the contingency. Generally, this involves moving from continuous to partial reinforcement, fading from some situations and not others, and providing self control. Among the issues involved in behavioural maintenance is generalization; both the acquisition of new and inhibition of old responding. The general rule is that generalization should be programmed rather than assumed to be a natural consequence of therapy. Thus, work done in the clinic or with the clinician needs to be conducted in or translated into the natural environment. This will also involve identifying the important cues that control behaviours and ensuring that


Treating clients

the behaviour is acquired or extinguished in the presence of these. You will need to train the client to identify the discriminative stimuli that operate in the environment and fade out prompts and reinforcement. In terms of the context, it is useful to identify a class of stimuli that learning theorists have called occasion setters (see Pearce & Bouton, 2001). These variables do not cause a response in and of themselves, but they set the stage for the occurrence of a response. For instance, a context may act to indicate that a particular set of contingencies are in operation (e.g., a police warning that on a public holiday weekend they are going to punish speeding with higher fines). Related are conditioned excitors and conditioned inhibitors. For example, a conditioned inhibitor is a stimulus that acts to suppress responding (e.g., a person with agoraphobia may learn about safety signals, in that panic may be less likely to occur in the presence of some stimuli, so these acquire the ability to suppress fear).

Self management

Contingency management involves procedures to increase desirable and reduce undesirable behaviours. The client tends to be viewed as a passive recipient of treatment in that behaviour is controlled by the environment and modifying the environment will modify the client’s behaviour. In contrast, self-management therapy is based upon a participant model of treatment (e.g., Kanfer & GaelickBuys, 1991; Page, 1991b). The responsibility for change is viewed as lying within the client and therapy is part of a transition to self-control. The therapist continues to play an important part in providing the context for change, but the burden of engaging the change process is left with the client. The main reasons for a self-management role are that (i) many behaviours are not easily accessible for observation by anyone but the client, (ii) change is often difficult, unpleasant and conducted with ambivalence and therefore collaboration and negotiation are needed, and (iii) the aim of psychotherapy is to teach generalizable coping strategies, not just management of specific problems. That being said, selfmanagement is best considered as a way of delivering contingency management rather than as a distinct technology. Self-regulation develops out of social learning theory in which behaviour is seen to arise from learning and complex chains of behaviours become more automatic through repetition. The greater the automaticity of a behaviour, the harder it will be to control. Self-management procedures are then required when new behaviours must be learned, choices need to be made, goals are to be achieved or blocked, or when habitual response sequences are interrupted or ineffective. Self-management brings into play controlled cognitive processing.


Behaviour therapy

Finally, there is a self-reinforcement phase in which the person reacts cognitively and emotionally to the self-evaluation which motivates change. During the final stage two attributional processes come into play. The person must correctly attribute both the cause and the control of a behaviour to something under their influence/control. Since self-management will require a degree of motivation, the strategies of Motivational interviewing (Miller & Rollnick, 2002) will be useful in recruiting and building motivation for change. Motivational interviewing will be described later in Chapter 10 but for now some of the key interventions and techniques involved are summarized in the following. Express empathy Warm reflective listening during which you work to understand the clients, accept them as who they are, acknowledge their feelings without judging, criticizing or blaming. Acceptance is not identical to approval, but will facilitate change, while confrontation will inhibit change. Develop discrepancies The discrepancy in life goals between where a client is and where they would like to be can be used to motivate change. Avoid argumentation Arguments encourage resistance and are frequently counterproductive and for this reason they are best avoided in psychotherapy. Roll with resistance Respond to force by side-stepping and then using the force to achieve therapeutic goals. Support self-efficacy Although the non-contingent encouragement of selfesteem has been questioned (Baumeister et al., 2003), self-efficacy is an important predictor of behaviour and its enhancement (discussed later) increases the probability that a desired behaviour will be engaged in. Use behavioural contracting

One particular motivational strategy is behavioural contracting. Contracts can help to assist clients to initiate specific actions, identify criteria for success, and to clarify the consequences of particular behaviours. When negotiating contracts with clients it is useful to (i) describe the behaviour in detail, (ii) identify criteria (e.g., duration or frequency) for completion of a goal, (iii) specify nature and timing of contingent positive and negative consequences upon fulfilment and non-fulfilment of the contract along with a bonus indicating additional positive rewards if a minimal criterion is exceeded, and (iv) clarify how the behaviour will be observed, measured, recorded and conveyed back to the client (if a third party is involved). If possible, a public commitment to the contract can be useful as a means to enhance compliance, but caution needs to be exercised if the consequences of a public failure would be detrimental.


Treating clients

Once a sufficient motivational foundation has been laid, self-regulation begins with the self-monitoring stage, in which clients monitor and evaluate their behaviour. Self-evaluation involves a comparison between the person’s actual behaviour and his or her standards for that behaviour. Even though selfmonitoring may lack validity for experimental purposes, many of the reasons that make it problematic for research become assets for clinical work. In particular, we know that performance is reactive and therefore, monitoring may have a therapeutic effect. Baseline data can be used to provide an incentive to change and as encouragement when change occurs. You can also select to measure a response that is incompatible with the problem behaviour. For example, spouses may be asked to record the interactions that lead up to a fight. This makes them conscious of those interactions that are leading to a fight and by inducing the awareness, increase the chances that alternative responses will be engaged. Once monitoring has begun it is possible to start modifying the environment and the contingencies. Stimulus control is a useful self-management procedure since the client can construct conditions which reduce the possibility of an undesired behaviour. For example, a person with a gambling problem may put restrictions on a bank account and a person with a drinking problem may choose who they are going to drink with. Alternatively, stimulus narrowing may be used to decrease the range of stimuli or environments under which the behaviour occurs. That is, the behaviour is gradually put under the control of certain discriminative stimuli. For instance, sleep hygiene rules (Van Brunt et al., 1996) encourage the use of a bed for sleeping, and stipulate that other behaviours (e.g., watching TV, reading, etc.) are to be carried out in other locations. The aim of these procedures is to narrow the stimuli that are associated with sleep. When introducing self-management procedures, it is helpful to consider how difficult they are for the client to execute. Task assignment is managed so that assignments are graded in difficulty and begin with the easier ones. These homework (sometimes more fruitfully called active practice) assignments need to be presented to clients as essential to the process of therapy. To learn selfmanagement, clients need to practice self-management. This will involve (i) information, in which the requirements of task are made explicit, (ii) anticipatory practice in which the client imagines and practices the assigned task within the safety of the therapeutic context (e.g., role plays), (iii) active practice (or response execution) in everyday settings, followed by (iv) a review. The review aims to translate the episodic memory that the person will have of an event into a semantic memory so that clients will form general rules and create knowledge about themselves and appreciate the meaning of events. The data


Behaviour therapy

routinely collected as part of measurement and monitoring activities can be useful in demonstrating the effectiveness of the behaviours to the client. In summary, when using self-management models, the client controls the contingencies of reinforcement. Behaviour is then rewarded or punished according to specified rules, as in contingency management, but their implementation is under the control or management of the client. However, learning can occur without the use of external reinforcement and one important method is through procedures associated with social learning theory. Modelling

Modelling and its use in behaviour therapy (and CBT) draws on an extensive empirical literature in psychology more generally (Bandura, 1977; Rosenthal & Steffek, 1991). Modelling describes the learning that occurs from the observation of others and any imitative change in behaviour that may follow. Therefore, it refers to changes in the behaviour of the individual who observes another (i.e., the model). Two subsets are observational learning and imitation. Observational learning is learning that occurs from observing others (e.g., children observing adult behaviour) and imitation refers to the behaviour of a person who observes and then copies the actions of others. There is some evidence (Litrownik et al., 1976) that observational learning is relatively more important than imitation for the transfer of learning because seeing repeated instances of a behaviour in different contexts allows an observer to formulate the rules that are important for generalization. In contrast, the imitative component facilitates acquisition because the observer engages in repeated practice. For modelling to be most effective (Bandura 1977) the observer must attend to the modelled events. Optimal models are distinctive. By being unusual, the model gains attention but, if too distinctive, the model will be perceived as dissimilar from the observer and modelling will be reduced. Other factors to consider in modelling are the affective valence of the behaviour (pleasant behaviours are more likely to be modelled than ones which are anxietyprovoking or unpleasant to perform), complexity (complex behaviours may be broken down into simpler and shorter components to facilitate attention to the relevant components), the functional value to the client (behaviours that are valued by the client are more likely to be attended to), and the prevalence of models (the greater the number of and the greater the consistency within the models, the greater the likelihood that the observer’s attention will be gained). When using modelling it is important to take into consideration the characteristics of the observer to ensure that they have the appropriate sensory capabilities and that their perceptual set will allow them to perceive the


Treating clients

important features (priming an observer about what to look for is useful). A therapist will need to ensure retention of relevant information and describe the behaviours in terms the client can understand. Consequences that flow from engaging in the behaviour can strengthen recall and encourage imitation. Motor reproduction of the model’s behaviour with therapist feedback will facilitate greater acquisition of the desired behaviour. Finally, it is important to ensure that when the client exhibits the desired behaviours that there is external reinforcement, such as praise by the therapist, self-reinforcement, or the natural rewards that occur from performing the responses in the natural context, and that the client identifies the positive consequences that follow the desired behaviour. Modelling can be divided into a variety of types. First, graduated modelling is used when clients are capable of performing some components of the desired behaviour. Graduated modelling often involves assistance in the patterning of behaviours so that the appropriate elements are performed in their correct sequence. Guided modelling is also graduated but adds guided practice. For instance, you may guide the observer to correctly emit an appropriate behaviour that has been modeled and then reinforce appropriate responding. Participant modelling involves modelling by the therapist, who then remains with the client and participates during the task. The presence of the therapist provides social support as well as enabling the therapist to solve problems that arise during the process. Covert modelling allows the client to imagine a model performing the appropriate behaviour. This requires careful description by the therapist and outcome is maximized when similarity of the model to the observer is greatest. In all of these different forms, an important dimension to consider is the difference between coping and mastery. Mastery models show perfect performance and depict the ideal behaviour that the observer is to imitate and acquire. Coping models, on the other hand, exhibit flawed performance that gradually becomes more competent and the model demonstrates coping with errors and setbacks. Coping models are often preferred to mastery models. For example, in our training clinic we have found that trainee therapists initially prefer to observe more senior trainees engaged in clinical work than experts, since while they can see the skill of master therapists, these skills seem too far beyond them at the present. Modelling has many applications, but we will illustrate one usage in the training of social skills. In this context a clinical psychologist will begin with an assessment of social skill deficits, including the expressive features of language, speech content, the paralinguistic elements (e.g., volume, pace, pitch, tone, etc.), non-verbal behaviours (e.g., proxemics, kinesics, eye contact, facial expression), response timing, receptive features of social interactions (e.g., attention,


Dialectical behaviour therapy (DBT)

decoding, etc.), contextual and cultural mores, and specific deficits (e.g., assertiveness). Once the deficits have been specified, appropriate behaviours are taught using direct behaviour training. Role-plays, in which the client makes an attempt to produce the desired behaviour, are used along with a demonstration by the therapist of the target behaviour in the form of a modelling display. Thus, there is role-reversal. This role-reversal will provide extra information about the client’s perceptions and abilities. The role-reversal also provides an opportunity to allow the client to experience thoughts and feelings associated with being the other person in the interaction. The role-play is repeated, but the client now tries to incorporate the new behaviours into their repertoire. The clinical psychologist will provide response-specific feedback, giving praise for successive approximations and concrete instructions for change in future rehearsals. When giving feedback it is useful to begin with positive feedback, then negative, and finally some more positive feedback so that the client does not feel overwhelmed with criticism. The role-reversal continues with repetition of the cycle that may include response escalation and variation, to enhance the flexibility of the client’s skills and to overtrain responses, so that they appear more naturally. Initially role-plays should be brief, highly structured and deal with relatively benign topics, until the client becomes comfortable with the procedure and has begun to acquire the principles. Finally, the client practices outside the therapy sessions to consolidate skills to generalize the behaviours.

Dialectical behaviour therapy (DBT) Dialectical behaviour therapy (DBT; Linehan, 1993a, b) is an adaptation of the behavioural techniques and is worth considering in some detail for two reasons. First, the treatment has empirical support for managing symptoms of Borderline personality disorder. Second, it is an illustration of how existing therapies can be modified to suit particular domains and the techniques of acceptance and validation are being incorporated into many newer variants of CBT with promising empirical bases (e.g., ACT; Hayes et al., 1999; Hayes & Strosahl, 2004). Thus, rather than describing the particular techniques of DBT (see Linehan, 1993b), we will focus on the novel ways that Linehan presents psychotherapy. Linehan suggests Borderline personality disorder evolves within an emotionally vulnerable individual who develops in an invalidating environment; Individuals who are emotionally vulnerable are more sensitive to stress and therefore stressors elicit excessive responses and it takes a long time to return to a baseline level of functioning when the stressor has finished. An invalidating environment occurs when a child’s experience and behaviours are disqualified or discounted


Treating clients

by people who are important to the child. The children’s utterances are not accepted as valid descriptions of their feelings or even if they are accepted, the person rejects the feelings as a valid response to the stress. When a high value is placed upon self-control then any perceived deficiencies in self-reliance are taken to indicate that the child lacks motivation or is disturbed. DBT recognizes the difficulties faced by an emotionally vulnerable person living in an invalidating environment and identifies three dialectical dilemmas. Individuals may not learn to identify and comprehend feelings. When feelings are recognized, they will be judged to be invalid. Further, growing up in an invalidating environment may inhibit children learning appropriate coping strategies to manage intense emotions. The paradox of the invalidating environment will cause an alternation between excessive emotional inhibition (to elicit acceptance from significant others) and extreme emotional expression (to elicit acknowledgement of feelings by others). This seemingly erratic behaviour will bring about erratic schedules of reinforcement, which in turn will strengthen the erratic behavioural patterns. To Linehan (1993a) this situation is the primary dialectical dilemma: both inhibition and expression of emotions become distressing. A second dialectical dilemma arises because one emotional trigger is not resolved before another stressor occurs. This blurring of unresolved stressors and the associated emotional reactions produces a series of unrelenting crises. A third dialectical dilemma is the alternation between active passivity and seeming competence. They will convey a sense of competence in an effort not to be determined by a current mood state, while simultaneously seeking out people to solve their problems. Thus, Linehan’s (1993a) therapy is dialectical because it presumes that for any issue (i.e., the thesis), there is an alternative position (i.e., the antithesis), and that one arrives at a synthesis through the clash of these two positions. The synthesis is not a compromise, but is a third way that takes the assets of each position, leaves their deficiencies, and resolves any contradictions. The key dialectic in DBT is the balance between acceptance on the one hand and change on the other. Any attempt by the patient at self-invalidation is balanced with training in adaptive problem solving techniques. In addition, given the emotional vulnerability of clients with Borderline personality disorder the therapeutic relationship is of central importance within DBT. Therapists are responsive to client, express warmth and genuineness. They use appropriate self-disclosure on the one hand and irreverent communication on the other. The irreverence involves confrontational communications that aim to nudge the client when therapy appears stuck or moving in an unhelpful direction. Linehan (1993a) encourages therapists to adopt a perspective that, despite appearances,


Cognitive therapy

clients are doing their best. Therapists are reminded of the therapeutic model within which the behaviour can be understood as a reasonable reaction of an emotionally vulnerable person to an invalidating environment. This acceptance is balanced with the dialectic of change. That is, even though the reaction is understandable, clients need to work to change the situation. The client may not be the (sole) cause of their current circumstances, but they can choose to be responsible for change. One valuable contribution of DBT is that it identifies a therapeutic hierarchy. Decreasing suicidal behaviours is the first priority in therapy and therapy interfering behaviours is the second. Therefore, if either of these behaviours is signalled, these become the focus of therapy until they are dealt with. Other goals moving down the hierarchy are to decrease behaviours that interfere with the quality of life, to increase behavioural skills, to decreasing behaviours related to post-traumatic stress, and to improve self-esteem and specific behavioural targets. However, a drawback of a rigid, therapist-supplied hierarchy is that it could be at odds with both a science-informed approach to clinical practice and with a key ingredient in the therapeutic relationship shown to be related to positive treatment outcome. That is, the order of treatment goals should be informed by a case formulation incorporating practice-based evidence and should be negotiated in a collaborative manner with the client. In summary, behaviour therapies extend from relatively straightforward contingency management to more complex treatment regimes found in DBT. In addition, they are typically delivered alongside cognitive interventions, even though they evolved separately.

Cognitive therapy One of the central techniques in cognitive therapy is Cognitive restructuring. Within Ellis’ (1962) Rational emotive therapy (RET) it is argued that Activating events (called As) do not cause emotional and behavioural Consequences (called Cs), but that thoughts or Beliefs (called Bs) intervene as mediators. For example, an activating event, such as preparing to consult with one’s first client, does not cause the emotional consequences of anxiety, but the emotion is mediated via beliefs such as, ‘‘I must be a perfectly competent therapist or I am a professional failure’’. Psychological disorders arise when the beliefs are irrational. By irrational Ellis means that they are unlikely to find empirical support in the person’s immediate environment and do not promote survival and enjoyment. Although there are many irrational beliefs, Ellis argues that they can be distilled into a relatively small set of basic irrational thoughts (see Ellis & Harper, 1975).


Treating clients

Therefore, Ellis would argue that the preceding example is an illustration of a basic irrational belief such as, ‘‘you must prove thoroughly competent adequate and achieving’’ (Ellis & Harper, 1975, p. 102). Treatment adds D and E to the ABC model, where D refers to Disputing the irrational thoughts and replacing them with more rational thoughts. This is achieved though a Socratic dialogue and a logic-empirical method of scientific questioning, challenging and debating. The consequence of replacing the old beliefs with the new more rational ones is more positive Emotions (i.e., Es). Rational thoughts are based on objective facts and if acted on will lead to a preservation of life, a more rapid achievement of one’s goals, and prevent undesirable conflict (Ellis & Harper, 1975). Thus, the procedural steps of RET are to (i) persuade the client that an RET analysis of the problem is useful, such that the client is convinced of the mediating role of cognitions, (ii) identify the most important irrational beliefs underlying the present complaint, which can be achieved using a case formulation approach described in Chapter 4, (iii) show the client how to dispute the irrational thoughts, and (iv) to generalize learning so the client can apply the newly-acquired knowledge and skills without the assistance of therapy. Once the core irrational beliefs have been identified the aim is to challenge them. The clinician achieves this goal by asking questions such as, ‘‘What thinking errors are you making?’’, ‘‘What is the evidence for what you thought?’’ and ‘‘What is the effect of thinking the way you do?’’ In so doing Ellis would argue that one looks for thinking errors such as Awfulizing (e.g., it’s awful when I’m stood up’’), I can’t thoughts (e.g., ‘‘I can’t bear it when you ignore me’’) and Damning (e.g., ‘‘You deserve to burn in hell for what you did to me’’). Similar to Ellis’ RET is Beck’s cognitive (behaviour) therapy. Beck’s approach clearly focuses on cognitions, but there is an added behavioural emphasis, especially with behavioural experiments (Bennett-Levy et al., 2004) that is less apparent in RET. Beck (1967) assumes that emotional difficulties such as depression and anxiety arise from negative automatic thoughts. They are negative in emotional content and automatic in the sense that they appear to occur involuntarily, and consequently are not easily dismissed. Depressed thinking is characterized by the cognitive triad: negative thoughts about the self, the world and the future. Overlaid on this content are cognitive processes (attention, abstraction and encoding) that transform environmental stimuli. Beck argues that these cognitive processes are biased (cf. Williams et al., 1997) which have the consequence that anxious and depressed individuals tend to make judgements in a systematic and consistent manner. The biases identified are (i) Selective abstraction, which describes forming conclusions based on isolated details of a single event (e.g., ‘‘I had a bad therapy session because I forgot one question’’),


Cognitive therapy

(ii) Overgeneralization, which involves holding extreme views based on particular events and then generalizing the conclusion (e.g., ‘‘I had trouble with my first client, therefore I must be a failure as a clinical psychologist’’), (iii) Dichotomous thinking, which includes thinking in all-or-nothing terms (e.g., ‘‘My first client was a success, but I just know my second will be a failure’’), and (iv) Personalization, which describes incorrectly making an inference about one’s self, based on an external event (e.g., ‘‘My client has cancelled, therefore I must be a bad therapist’’). These cognitive processes harden into stable characteristic cognitive beliefs (called schemata) that Beck argues render people vulnerable to anxiety or depression. To identify and modify these dysfunctional beliefs, the first step is to identify automatic thoughts. This is achieved by getting the client to monitor automatic thoughts, which are verbal thoughts or images that seem to arise without effort and are associated with negative emotion. Clinicians can elicit these thoughts by asking clients to introspect (e.g., ‘‘What’s going through your mind right now?’’). For instance, you might ask a client to try to identify the automatic thoughts that occur when you notice an abrupt shift in mood in a session, you could use evocative, personally-relevant role-plays, you might model the process by thinking aloud your own automatic thoughts. Burns (1980, 1999) has described a downward arrow technique that can be very helpful. The clinical psychologist identifies an important automatic thought that could arise from an underlying dysfunctional belief. By repeatedly asking the client the meaning of the thought (e.g., ‘‘What’s the worst thing that could happen?’’ or ‘‘What would be upsetting about that?’’ or ‘‘What would that mean?’’) the clinician aims to spiral down towards the dysfunctional belief. Other methods to help clients focus on the content of cognitions are to help them to attend to global words (e.g., always, never) and imperatives (e.g., must, should, and ought), exploring a client’s explanations of negative or positive moods, and attending to self-referent thinking. The clinical psychologist might also want to focus on the form of the cognitions, by drawing the client’s attention to typical cognitive biases and asking about the degree to which these are used in other areas, especially those where emotional problems are observed. Therefore, during the session with a client, the observation of intense emotion may suggest the activation of more central automatic thoughts. Outside the cognitive therapy session, clients are encouraged to maintain a record of the automatic thoughts and their effects. In a series of columns, clients record activating events, the accompanying emotion (rated from 0100 in terms of intensity), a written verbatim record of the automatic thought, and finally the degree of belief in the thought (0100). Clients are then encouraged, first within the therapy session and then more often on their own outside of


Treating clients

therapy, to challenge the automatic thoughts. Similar to RET clients will assess (i) the evidence for a thought by asking ‘‘What is the evidence?’’ or ‘‘How could it be tested?’’, (ii) evaluate alternative ways of thinking, by posing the questions ‘‘Is there another way to look at it?’’ or ‘‘What can I do about it?’’, (iii) consider the implications of a way of thinking by asking ‘‘What is the effect of thinking?’’ or ‘‘What is the worst that could happen?’’, and finally (iv) identify any thinking errors. The aim in each of these activities is to identify a new more helpful and believable thought that leads to a more positive emotional reaction. One issue of relevance to cognitive therapy is the role of unconscious thoughts. For example, it has been long argued that we only have access to cognitive products, not cognitive processes (Nisbett & Wilson, 1977). We might know that we decided to choose clinical psychology as a profession, but we do not have direct access to the reasons why we made this choice (even though we believe we do). That is, much thought is unconscious and inaccessible but we continue to answer ‘‘why?’’ questions, even though we arguably do not have access to the data. This could be a problem for cognitive therapies if one believes that clients truly cannot get access to their automatic and irrational thoughts. However, it is also possible to assume that in therapy we are evaluating the evidence for and against different thoughts and we decide on which are best accounted for by the data. This latter position is agnostic as to whether we have direct access to automatic thoughts, by only assuming that we can evaluate and change our belief structures. Presenting a rationale for cognitive therapy

When conducting any psychological treatment, presentation of a rationale is critical. Giving a rationale is part of the broader goal of orienting a client to treatment, which has been identified as a clinical activity that is predictive of positive therapeutic outcomes (Orlinsky et al., 2004). The challenge when giving a rationale for cognitive therapy is no different to any other therapy, since it is important to present the treatment in a manner such that the client understands it sufficiently well to be able to comply and so that sufficient hope and motivation are recruited to encourage the client to want to comply. Therefore, the principles of treatment need to be outlined and any potential objections must be addressed. For example, in outlining a rationale for cognitive therapy in which cognitions are postulated to mediate the emotional responses to antecedent events a few points are worth bearing in mind. First, the language must be clear, simple and appropriate to the client. By way of example, if you consider the first sentence in this paragraph, you could well find that phrases such as ‘‘cognitions are postulated to mediate emotional responses to antecedents’’ could be better expressed for clients as, ‘‘You’ve been telling me that your husband makes


Cognitive therapy

you angry, but although it might feel as if he causes you to feel angry, it is what you think about in your head that causes you to feel bad. Now, I understand that the idea that he doesn’t cause you to be angry may sound pretty strange so let me give you an example . . .’’. The jargon has been avoided and also a common client reaction to a cognitive rationale has been anticipated by using the phrase ‘‘. . . I understand that the idea . . . sounds pretty strange’’. Our rule of thumb is that if any word or phrase needs an explanation, then you are better off delivering the explanation than using the word. That is, if you need to tell the client what cognitive means, why use the word in the first place? Sometimes it will be useful to teach clients names and phrases to facilitate communication, but the main goal is therapy not education about therapy and so we suggest keeping jargon to a minimum. A second point is to try to make the rationale memorable. Since the rationale is a key point in therapy, you want to do everything you can to help the client focus on it and remember it. One way to do this is to use a memorable metaphor/illustration. Sometimes the client will have already given you an illustration (e.g., a client with panic disorder and agoraphobia might have said, ‘‘as I stood in the queue at the supermarket I started to worry that I might not be able to get out in case of a panic and then whoosh, there was the panic’’) or you might choose a metaphor based around a client’s interest. One example might be as follows: ‘‘Let me try to show you what I mean about thoughts causing feelings. The other day I was driving along like normal and feeling fine. All of a sudden I caught sight of a police speed camera by the side of the road and I thought ‘‘did I just see it flash?’’ I quickly braked; I felt panicky; my heart started to beat fast and my hands got sweaty; I began to worry that I’d have to pay a fine and I didn’t have the money. Then I realized that the camera hadn’t flashed and so I hadn’t been caught. A wave of relief swept over me and I drove on comfortably.’’ You can then discuss with the client what caused your emotional reactions, by asking if the speed camera had caused your emotional response (e.g., ‘‘how did the speed camera sitting by the side of the road cause my heart rate to increase?’’) and what causes the changes in emotions (e.g., ‘‘how did the unchanging speed camera cause both anxiety and relief?’’). Sometimes starting with these illustrations can be difficult if the client responds by indicating that their emotional problems are different to the example given. Usually, however, they can help clients to see clearly relationships that can be obscured when they try to reflect upon event-emotion sequences that have been occurring for a long time or when the emotions are very intense. Thus, beginning to develop a suite of rationales is a good therapeutic skill. In the process of presenting a cognitive rationale, clients will often object to the ideas and it is wise to tackle these head on. For example, clients may say that


Treating clients

a cognitive approach is cold and cerebral. One way to respond to this is to ask them to imagine a distressing situation and see if it elicits an emotional response. If so, then you can respond that it is this kind of emotional response that can be triggered even by memories and thoughts that therapy is trying to tackle and the aim is to bring runaway emotions under control. Another objection clients may raise is that you are asking them to deny reality. One response is to reject this assertion and to indicate that the goal is not to deny reality, but to avoid making false assumptions, e.g., that the actions of others or events in the world can cause my feelings. Sometimes clients will respond that they must express their feelings and that cognitive therapy is about denying these feelings and their expression. A possible response to these concerns is to highlight that once you have a feeling it may be useful to express it, but suggest that cognitive therapy involves asking if you needed to have the feeling (or one of that intensity) in the first place. Clients might also claim that thoughts happen too quickly or automatically/unconsciously. One response to this client concern is to try an experiment. Write on a piece of paper, ‘‘a pen without ink is no use’’ and ask the client to read the sentence aloud. Then write, ‘‘I prefer to use a pen that works’’ and ask the client to do the same. When the client has said these two sentences, ask them why they pronounced the word use differently. Some clients will recall enough grammar to explain why, but most will respond that they ‘‘just knew it from the context’’. Yet we have not found a client who will attest to having consciously articulated the grammatical rules to decide between possible pronunciations. This allows you to illustrate that there are rules/beliefs that we have learned and we can infer their current operation from our behaviour, but they may be so practiced that they no longer need to be articulated. Having made this point, the question needs to be turned back on the client by posing the question; just because it has been that way does it always have to be that way? At this juncture, examples of learning to drive and then travelling to a country where the practice is to drive on the opposite side of the road may be useful. Although driving on one side of the road was learned and became automatic, nonetheless it is reversible with effort and concentration. Sometimes clients might respond that cognitive therapy sounds too idealistic, to which one could respond that therapy is about giving choice. Emotions are a cue to initiate a self-inventory and change associated thoughts if you wish. There is no imperative to changing your unhelpful thoughts. Finally, clients later on in cognitive therapy may indicate that they believe the rationale intellectually, but not emotionally. One way to address these concerns is to reframe believing intellectually as an initial sceptical belief. It reflects an openness to be convinced by the evidence and therefore the client can be encouraged to take the cognitive rationale and ‘‘try it on for size’’ or to ‘‘borrow the belief for a while and see what happens’’.


Basics of interpersonal psychotherapy (IPT)

Thus, the issue becomes an empirical question that client and therapist work on together. In summary, cognitive therapies focus attention on modifying psychological problems by identifying and then working with the client to modify thoughts and beliefs that are postulated to intervene between the activating event and the problem emotion or behaviour. More recently, cognitive therapies have started to move away from a focus on the content of cognitions and towards the underlying cognitive processes. For example, Wells emphasizes the role that metacognitions play in selecting cognitive processes which in turn can influence cognitive content. In a similar vein, Hayes and colleagues (Hayes et al., 1999; Hayes & Strosahl, 2004) in their Acceptance and commitment therapy (ACT) focus on the cognitive processes clients use when responding to unwanted thoughts and emotions, and suggest replacing avoidance with an attitude of acceptance. These treatment developments are promising, but to date have not had sufficient time to enter the listings of empirically-supported treatments.

Basics of interpersonal psychotherapy (IPT) In contrast to the focus of behavioural and cognitive therapies, interpersonal psychotherapies emphasize different factors in treatment. Interpersonal psychotherapies have been found to be efficacious for depression and some personality disorders. As you may recall from Chapter 4, an Interpersonal psychotherapy (IPT; Klerman et al., 1984; Klerman & Weissman, 1993) approach conceptualizes treatment as falling into three phases. The first phase of assessment and orientation to therapy has been covered earlier. Therefore, the present discussion will focus on the middle phase, in which problem areas are selected and treatment is engaged in, and the termination phase. During the middle phase the clinical psychologist using IPT will (i) facilitate a discussion of topics that are relevant to the problem area, (ii) maximize selfdisclosure by fostering a strong therapeutic relationship and identifying topics which heighten the client’s affective state during therapy, and (iii) ensure the smooth passage of the client through therapy by identifying therapy-interfering behaviours. A session of IPT will often begin by asking the client, ‘‘Where should we focus today?’’ This contrasts with CBT, where the direction of treatment is more often managed by the therapist. Thus, the client chooses the topic for discussion and can change focus from a previous session. One particularly good point about this opening is that it gives a client license to bring up previously unmentioned problems. However, the novice clinical psychologist needs to be


Treating clients

cautious at this point because you run the risk of having therapy hijacked by clients who skip between topics without resolving any issue. Notwithstanding, once the focus of the session has been decided upon, the therapist will move through four developmental stages in therapy. First, the clinical psychologist will explore the problem area. Second, the therapist will focus on the client’s expectations and perceptions, then analyze alternative ways to handle the problem area, and finally work with the client to initiate new behaviours. For example, if the problem area is one of an abnormal grief reaction, then the first stage of problem exploration could involve an analysis of points at which a client fails to move through the grieving process or in which the mourning process has become distorted (e.g., depression in the absence of sadness), delayed (e.g., when grief is experienced long after a loss), or prolonged. The perceptions and expectations could be explored by a discussion of the client’s life with their loved one and their life in the present. This discussion will move into treatment, which will aim to facilitate the mourning process and help the client re-establish interests and develop new relationships. The particular strategies that could be used include a non-judgemental elicitation and exploration of feelings by encouraging the client to consider the loss, to discuss events surrounding the loss and the consequences of those events, with a view to bringing out any associated feelings. Often clients need reassurance that grief is not a sign of abnormality and therefore a discussion of both the typical grief process (and the variability therein) can be beneficial to facilitate the client discussing, experiencing and owning the distressing feelings. During IPT a clinical psychologist might try to shift a client from the death per se, because a fixation on the death as such can lead to avoidance of some of the complexities within the relationships with the deceased. By discussing both the factual details of the dead person and the client’s affective experiences to the dead person (both when alive and in the present context) it may be possible to move through some of the negative feelings feared and avoided by the client. In so doing, the client will be able to identify a new formulation of the relationship and understand the memories of the dead person that incorporate both the strengths and the weaknesses of the relationship. As treatment moves into behavioural change, the clinical psychologist will seek to help the client to become more open to developing new relationships and in this way, the therapist can lead the client to consider new and different ways of re-engaging with people. A second area of focus in IPT is interpersonal role disputes, where the client and another person significant to them have non-reciprocal expectations about the conduct of a relationship or the roles therein. For instance, a married couple may have a dispute about the workfamily balance of each partner. The clinical


Basics of interpersonal psychotherapy (IPT)

psychologist begins by trying to identify the chief issues and clarify the nature of any dispute by highlighting differences in expectations and values between the client and their significant others. This will also entail considering both the client’s wishes about the relationship and the options and resources available to them. In addition, it is worthwhile spending time searching for patterns in behaviours (e.g., has the same issue appeared in previous relationships or does the same conflict manifest in a variety of presentations?) and if they exist, exploring the possible reasons. Moving to consider new ways to handle the issues, it can be useful to focus on avoidance of confrontation and an unwillingness to express negative feelings. If these unassertive behaviours are occurring, then treatment can involve assisting clients to devise strategies for managing the disputes and to resolve differences. A third target of IPT is role transitions, in which a person has moved from one social role to another (e.g., promotion, marriage, childbirth, etc.). Since people who do not cope adequately with transitions are at risk of developing depression, treatment will try to enable a client to view their new role in a more positive manner. By exploring both the (usually forgotten) negative as well as the positive aspects of a previous role, it may be possible to develop a more balanced view of the present circumstances while simultaneously working to restore the client’s self-esteem. In terms of new behaviours, IPT will encourage the client to initiate new relationships in their new role. This will require an assessment of the client’s social skills to determine the degree to which previously successful social skills may generalize to the new context and if new skills are required. Since some of the difficulties with role transitions arise because there is a loss of familiar social supports and attachments (often accompanied by a reduction in self-esteem to the extent that it was bound up in the previous role), and because there are demands for new social skills, the therapist should address these deficits. Once identified, the clinical psychologist will try to put the lost role in perspective by evaluating the activities and attachments that were given up, and by using the processes in IPT, such as encouragement of the expression of affect and training of required social skills, to help the client establish a new system of social support. Finally, IPT will focus on interpersonal deficits. These are targeted when it is apparent that a client lacks the skills for initiating or sustaining relationships. These deficits may be observable in the therapeutic sessions or from a review of the client’s life. Since interpersonal skill deficits remove a person from a major source of enjoyment, a major goal of the treatment is to reduce any social isolation. Maladaptive patterns in previous relationships will be sought and, if identified, the clinical psychologist will discuss with the client negative and positive feelings associated with these relationships. At this point the clinician


Treating clients

may explore with the client the feelings about the therapist and the therapeutic relationship, with the aim of using this relationship as a model for other relationships. That is, the therapeutic relationship can be used to help clients learn interpersonal skills which they can then apply outside therapy. In summary, IPT focuses treatment upon the interpersonal difficulties that may cause the presenting problem or may arise from it. In so doing, the treatment seeks to reduce the presenting problem by addressing issues that may cause or exacerbate the client’s difficulties.

Delivering empirically-supported treatments Having described some of the basics of behaviour therapy, cognitive therapy and interpersonal psychotherapy, it is worth bearing in mind that no psychotherapy can be completely captured in a description of its components. This is not to say that components cannot be isolated, manualized, and even automated using computerized technologies (Tate & Zabinski, 2003), but the ability to deliver the treatment in a manner that connects with the client is a critical skill. Therefore, we will conclude the chapter with two detailed examples of particular treatments, illustrating how they might be presented to a client. We present these not as scripts to follow, but as illustrations of how a treatment may be delivered to a particular client. Putting this another way, the manualization of psychological treatments has facilitated the dissemination and reproduction of treatments in the same way that musical annotation facilitated the dissemination of music. However, in the same way that a skilled musician interprets the notes or arranges a piece for different instrumentation, a skilled clinical psychologist will modify and adapt treatments so that they meet a client’s needs. The first example is graded exposure for a phobic anxiety and the second is relaxation. Example 1: exposure to feared stimuli

Exposure to feared stimuli is a broadly applicable treatment (Andrews et al., 2003) that has a strong empirical foundation. However, while the efficacy of exposure is not in question, the mechanism whereby the beneficial effects are brought about is not as clear as once thought. Procedurally, confronting a feared stimulus in the absence of aversive consequences parallels extinction as it involves the repeated presentation of a conditioned stimulus (CS) in the absence of the unconditioned stimulus (US), with the end result that a new contingency is learned. However, the procedure also parallels that of habituation and counterconditioning. For example, in systematic desensitization counterconditioning occurs as a client is first taught relaxation training so that they are able


Delivering empirically-supported treatments

to elicit the relaxation response rapidly and effectively. Once this skill has been taught, the client it taught to construct anxiety hierarchies so that feared stimuli are organized into a step ladder of fear. For example, a 100-point fear thermometer is used to help clients rank feared situations and stimuli in terms of the amount of fear elicited. Exposure (often in imagination) is then conducted, beginning with the least fear-provoking and during stimulus presentation the client is encouraged to relax, with the goal being that relaxation functions as a competing response inhibiting anxiety. If anxiety begins to escalate, exposure is terminated or reduced until relaxation dominates over anxiety. At this point exposure is recommenced. However, in contrast to counterconditioning, exposure is also effective when conducted in vivo without the buffering of anxiety and when high levels of anxiety are elicited (i.e., flooding). Further, a client needs to confront a feared stimulus, yet in some circumstances distraction from the stimulus appears to enhance the anxiety reduction both within (Johnstone & Page, 2004; Penfold & Page, 1999) and between (Oliver & Page, 2002) sessions. The variety of procedures (e.g., imagination versus in vivo; distracters present versus absent) and differences in the intensity of anxiety (e.g., systematic desensitization versus flooding) present difficulties for many different theories of anxiety (see Barlow, 1988; Craske, 1999, 2003). However, for a scientist-practitioner these differences are non-trivial, because a good conceptual understanding of the mechanisms whereby an intervention brings about its clinical effects is essential to good clinical practice. Without a strong theoretical foundation it is unclear how to apply a treatment under conditions that differ from a textbook situation, what factors to consider when a client does not respond as expected, and when clients present with a complex mix of different problems. One theory that can accommodate the variety of circumstances in which exposure reduces anxiety is self-efficacy theory. Bandura (1977) argued that all anxiety-reducing treatments shared the common property that they all increased the sense of competence in mastery regarding a fearful situation. Thus, successful mastery enhanced self-efficacy that in turn reduced avoidance. Self-efficacy predicts therapeutic outcome more accurately than arousal during treatment, anticipated danger, or perceived danger. Further, it guides treatment by suggesting that effective therapy will maximize the elements that enhance a sense of mastery. Another approach that can also accommodate the variety of situations within which exposure is effective is the more pragmatic approach typified by Barlow’s (1988) essential targets for change. Barlow first suggests that exposure should address action tendencies. Anxiety primarily involves action tendencies that are typified by vigilance, or a chronic state of readiness to respond. Consequently,


Treating clients

exposure treatment should aim to modify these action tendencies by encouraging approach rather than avoidance. All varieties of exposure share this as both a process and a goal. Second, Barlow identifies that a key belief structure/meaning proposition in anxiety appears to be the perception of a lack of control. Exposure exerts its effect in part by enhancing perceived control. Thus, during successful exposure and in combination with anxiety management strategies clients learn that they have increased control over the feared objects and situations themselves as well as the anxiety response. Finally, Barlow identifies self-focused attention as a critical variable. Anxiety is associated with self-focused attention in general and a self-evaluation in particular. Barlow (1988) cites evidence that clients fail to exhibit reductions in anxiety when they are in a self-evaluative mode, but that reduction of anxiety is greatest when attention is focused on the external and non-emotional aspects of the environment. Both Bandura’s and Barlow’s approaches mesh with an interesting review by Clum and Knowles (1991) about the factors that predicted which people with panic attacks would go on to develop agoraphobic avoidance. They claimed that it was not severity or frequency of panics, the age of onset, and probably not the duration of panic or location of first panic. Rather agoraphobic avoidance was predicted by negative outcome expectancies, the perception of a link between situation and panic occurrence, and self-efficacy. To the extent that these factors are generalizable, exposure should aim to do more than simply confront a person with the feared stimulus. The treatment should also aim to change outcome expectancies, which it could do through psycho-education and successful experiences of confronting feared stimuli and situations. Secondly, the treatment would aim to modify a perception of a link between situations and panic and anxiety, by changing causal assumptions through cognitive therapy and by using exposure to test false beliefs about the danger inherent in situations and establish new learning that promotes less anxiety. Thirdly, exposure treatments should aim to enhance self-efficacy. It appears that exposure to feared stimuli is associated with enhanced self-efficacy per se (e.g., Oliver & Page, 2002) but these changes could be enhanced by teaching emotion and problem-focused control strategies in addition to successful experiences of confronting feared stimuli. With these principles in mind, it is possible to examine some questions about the conduct of exposure to feared stimuli. A first question is, how much anxiety should be permitted? Given the aims are to extinguish anxiety, it is important to have as much as possible, but since the aim is also to change cognitions and enhance self-efficacy, this goal can be balanced with the aim of eliciting as much anxiety as the client can manage (most often achieved by grading the exposure tasks). Although grading exposure does not appear to be essential, graded exposure is preferable because it tends to have lower dropout rates than flooding.


Delivering empirically-supported treatments

A second question is, how similar to the feared situation or original trauma does exposure need to be? In general the closer the exposure situation resembles the actual situation, the greater the anxiety-reducing effects will be (Andrews et al., 2003). This is important to remember when using imaginal exposure, but it also needs to be borne in mind that although in vivo is generally superior to imaginal exposure, better imaginers improved more with imaginal exposure (Dyckman & Cowan, 1978). Further, imaginal exposure is excellent for filling in steps that aren’t possible in real life (e.g., having a plane take off for one metre and land again) or undesirable or impractical to replicate (e.g., a trauma), but transfer from imagination to real life is only around 50%. A third issue concerns the temporal parameters of exposure. Broadly speaking, the more frequent and the closer the sessions, the stronger the treatment effect, and longer sessions (i.e., until anxiety reduced to around 1020%) appear better than shorter ones (due to the risk of sensitization). These factors allow anxiety to reduce and the person’s expectations and beliefs to change as he or she comes to feel in greater control of the anxiety. Having discussed these general principles, we will illustrate how a therapist may present a rationale for exposure to a client and then proceed to introduce exposure hierarchies. Therapist A universal truth about anxiety is that avoidance makes fears worse. This is the case because first, anxiety is unpleasant, second, avoiding fear-provoking situations or activities stops anxiety, and third, escaping when anxiety is rising brings enormous relief. Client It sure does. Getting away from spiders is the best thing I can do. T In the short-term avoiding is the most sensible thing to do, but what have been the longer-term effects? C I’ve just got more fearful and had to avoid not only spiders, but places where they might be. T And what happens when you escape or avoid these places? C I feel relief. T That relief is a problem because in the short-term, avoidance and escape give you a sense of control over your anxiety but in the longterm you spend more and more time organizing your life to avoid what you fear. In this way fear spreads throughout your life. Phobic avoidance develops a little like a child’s tantrum to get something to eat when out shopping. Supermarkets are designed so that the aisle containing the candies is far enough from the entrance that children have had time to get tired and hungry. When the candies finally come into view, the child throws a tantrum. To a frustrated parent,


Treating clients






the candies provide a simple solution to stop the noise and embarrassment. The problem is that the next time the parent ventures into the supermarket, a tantrum is even more likely. Avoiding or escaping from what you fear is like giving a kid a candy to stop a tantrum. Every time that you flee before your anxiety subsides, you make it more likely that you will be anxious the next time. But I’ve tried to face my fears, but it hasn’t worked. A common mistake made by people trying to manage fears is to progress too quickly. Their anxiety reaches very high levels and never goes down until the person runs away from the frightening situation. Is this what happened to you? It almost sounds like you were there! But I’ve tried so hard and it hasn’t worked. Putting in so much effort and not seeing any benefit can be very demoralizing. For that reason we are going to carefully monitor your anxiety to make sure that we can tell what we are doing is working and if it isn’t, we can re-think our strategy. What I am going to suggest is that we try a different way and face your fears gradually. To face your fears step-by-step, you first must clearly identify what you want to achieve. Your goal may be to go somewhere or do something that you presently find frightening. Remember, a goal is something to strive towards; don’t worry if you can’t achieve it yet. Later you’ll be able to break it down into easier steps. Let’s try to write down a goal. Well, I’d like to be able to walk into my house like a normal person and not have to check each room for spiders before I can feel comfortable. OK, let’s try to break this goal into smaller, easier steps. Each step must be specific and we’ll try to build a stepladder so that we begin with steps that cause little fear and anxiety and work up to something that is quite scary. Well I could begin by standing outside a room, but not going in. How much anxiety on our fear thermometer would that cause? About 10 out of 100. OK, that sounds like a good place to be, what might be a little more fear-provoking for the next step. Say around 20? The client and therapist then continue to work out the hierarchy.


Now we’ve got the anxiety stepladder, let’s get some guidelines in place for when we start to face these fears. First, I want you to agree


Delivering empirically-supported treatments




that you are going to do everything you can not to leave because of fear. Only leave once your anxiety has begun to decline. You will become panicky and fearful, but you can use the anxiety management techniques we’ve covered to control it. Is this absolutely necessary? What do you think? I guess so, because otherwise I’ll keep reinforcing the anxiety through relief. Well done. I know its going to be difficult, but this is the way to break the cycle. The next guideline will be that you will repeat each step until anxiety has decreased and your confidence has increased enough for you to attempt the next step. I’ll work with you to make sure that you don’t go too quickly or too slowly, but by facing your fears regularly and systematically, they will decrease. If that’s the only way. I know it will be hard, so don’t forget that after each attempt you reward yourself. No-one else understands how frightening your steps are for you, so praise yourself or give yourself a treat whenever you face your fear and your anxiety decreases. OK, I think I’m ready. Before we start, there is one last thing to mention and this is an important point to remember. When people start to face their fears, they feel as though they are getting worse. Their anxiety feels stronger and their ability to control it weaker. This experience is not only normal; it is a signal that you are beating your anxiety. Your anxiety is behaving like the child in the supermarket who screams to get a candy. The more you say ‘‘No’’, the louder your anxiety will scream to make you give in. Expect a tantrum  and we’ll work together to manage it without avoiding or escaping.

Example 2: relaxation

One treatment technique that has a broad application is relaxation. Borkovec et al. (1978) reported that progressive muscle relaxation was superior to a control condition in alleviating tension and the effects were maintained over 5 month follow-up. Although the effects of relaxation do not appear to be mediated by therapeutic suggestions (Borgeat et al., 1983), Agras et al. (1982) found that client expectations do affect outcomes. Clients were told to expect an immediate improvement or no immediate improvement and the results (for systolic blood pressure) were more favourable for participants in the former


Treating clients

group. Perhaps related to the enhanced expectations, Brauer et al. (1979) found that therapist-directed progressive muscle relaxation was more effective than audiotaped relaxation. Thus, the live training appears superior, perhaps because it enhances therapeutic expectations, or perhaps because the relaxation can be paced appropriately and the therapist can use visual cues to correct errors. However, relaxation requires sufficient practice and training to be effective. With the downward pressure on the duration of therapeutic contact, it is important to note that (Borkovec & Sides, 1979; Hillenberg & Colins, 1982), on average, studies that find that relaxation is effective use over five sessions of training. Studies finding no effect average only 2.3 sessions of training. Thus, relaxation is an effective method of anxiety management, but how is it to be delivered? In the following example, we illustrate how one might deliver a rationale and treatment with a client (see also Bernstein & Borkovec, 1973) who has already been explained many elementary aspects of anxiety and fear (e.g., the fightflight response). Client

But I keep getting these headaches from all the tension I’ve got. What can I do about that? Therapist Do you remember we talked about the flight or fight response and how it involves increased muscle tension? C Yes, so is that why I’ve got this muscle tightening when I’m worried or panicky? T Yes, and have you noticed what happens if the physical tension remains too high for too long? C I get exhausted and have headaches. T That’s right. So to overcome problem tension you will need to do three things. First, you’ll need to learn to recognize when you’ve got excess tension. Second, you’ll need to learn to relax it away and third to learn how to keep the excess tension away. The first step in all this is to separate good tension from bad tension. C But all tension’s bad. I want to be relaxed don’t I? T Think for a moment about playing tennis. Just before you receive a serve, what do you do? C I crouch and get ready to whack it back as hard as I can. T You tense up? C I guess so, but that’s so my muscles are ready for when the ball is served. T And when the point is over, what happens to your muscles? C They relax until I get ready to receive the next service.


Delivering empirically-supported treatments






So you see how throughout the game you alternate between being tense and relaxed? If you remained too tense between points you’d tire out, but if you relaxed before a serve you wouldn’t be ready. This tension is good tension because it is not too high for the task and it lasts as long it needs to. In the same way, you need to be more and less tense throughout the day. It is necessary to be more tense when driving a car than, for example, when watching television. I see that the tension increases my alertness when I’m driving, but I don’t need it when I crash in front of the TV. Absolutely. Now ask yourself, where you feel tense right now and then where you usually feel tense. On this sheet, put a tick against every area which is relaxed. Put a cross against every area that is tense. Leave blank any area which is neither tense nor relaxed. (See Table 5.1.) See how the areas of tension seem to group together, especially around your neck, head and face. No wonder I get these damned headaches. What can I do about them? What we need to do is to learn how to relax every muscle in your body by learning the art of muscle relaxation. I’ll give you a bit of the theory first and then go on to the practice, so we can start to learn it here and now. Let’s get on with it. OK. Well, you can defeat tension with relaxation because they work against one another. The more tense you become, the less relaxed you are. The more relaxed you become, the less tense you are. Both the flight or fight response and the relaxation response are controlled by part of your brain called the involuntary nervous system. One half of the involuntary nervous system triggers flight or fight, while the other half controls the relaxation response. These two halves work like a pair of scales. If you load one side of the scales with panic, fear and worry, you will have more tension than relaxation (because you feed the flight or fight response). If you load the other side with relaxation, you will have more relaxation than tension (because you feed the relaxation response). So this tension is why I feel keyed up and headachey? Tension can lead to all those things as well as backaches, sore muscles, nausea, stomach upsets and butterflies, and even trouble sleeping. What we’ve got to do now is to see how to control this tension with


Treating clients Table 5.1. Tension identification chart.

Body area

Where am I tense right now?

Where am I usually tense?

Neck and head  Neck  Scalp  Forehead  Eyes  Temples  Jaw Upper body  Shoulders  Top of back  Chest Hands and arms  Hands  Lower arms  Upper arms Lower body  Stomach  Base of back  Buttocks  Groin Legs  Thighs  Knees  Calves  Feet



something called progressive muscle relaxation. Let me show you what I mean. Try to tense the muscles around your eyes. Erm . . . I don’t know what you mean. How do I do that? Yes, when we try to get tense it’s difficult. Now try another way. Close your eyes tightly. You are now taking control of your muscles, making them do what you want. Once this tension is under control, relax the muscles by opening your eyes. I can see that. They were tense and then relaxed. Switching between tensing and relaxing in this way shows the two principles of physical relaxation. First, the muscles are deliberately tensed to take control of tension. The idea is not to increase physical


Delivering empirically-supported treatments






tension, but simply to tighten the muscles sufficiently for you to recognize physical tension. Second, the muscles are then relaxed. You can progressively work through your body, gently tensing and relaxing all your muscles in turn. In this way you can totally relax your whole body. Let’s start by learning how to identify and relax each muscle area, then you can begin a whole body relaxation session. Make yourself comfortable by sitting back in the chair with your legs uncrossed, feet firmly on the floor, and hand resting on your thighs. Try to relax your hands by first tensing them by curling them into fists. Then relax them by stopping making a fist and letting it fall. What did you notice? I could feel the tension grow and then fall away when I let it go. Excellent, that’s the funny thing about progressive muscle relaxation. Putting the tension in is the way to get control of it and let the tension go. Now let’s move up to your lower arms. Tense your lower arm muscles by lowering your hand. Bend it down at the wrist as though trying to touch the underside of your arm. You should feel the tension in your forearm. Relax the muscles by straightening the wrist again. Moving up now to your upper arms. Can I ask you to tense your biceps by bending your arm at the elbow, curling your hand towards your shoulder? This is the same movement that bodybuilders use to show off their biceps. Relax the arm by straightening it. Now let’s try the shoulders. Tense the muscles by lifting your shoulders. Hunch them up as if trying to cover your ears with them. Now relax by letting your shoulders drop again . . . To work on the neck, lean your head to the left until you feel the muscles tighten in the right side of your neck. Slowly and carefully roll your head forward, around to the right and then all the way back to where you started. One side of the neck will tense while the other is relaxing. If you feel any pain, you are stretching too vigorously. How does this feel? This is hard because it all feels pretty tense to begin with and the relaxing doesn’t seem as effective. It’s really good that you notice these things because remember that one of the goals was that you learned to recognize the tension. With practice you will get better at relieving the tension, but the first step is to become aware of the tension. Now have a go at the forehead and scalp. Tense these muscles by raising your eyebrows. Release the


Treating clients




tension by letting your face resume its normal expression once more. How was that area? Not as much tension as the neck. OK, let’s try the eyes. Tense the muscles around the eyes, hold, and then relax . . . We can do the jaw now. Tense the jaw by clenching your teeth (enough to tighten the muscles and no more). Relax by unclenching them . . . OK, moving to the chest, inflate your lungs to expand and tense your chest muscles. Hold the tension, then release by breathing out . . . Tense and relax the stomach. To do this, push your tummy out to tense your stomach muscles. Release by letting your stomach return to its normal position . . . Next we can do the upper back. Tighten the muscles by pulling your shoulders forward while leaving your arms by your sides. To relax, let your shoulders swing back to their usual position. Can you notice the difference between the tension and relaxation? Yes. The tension makes it easier to relax because all you’ve got to do is let the tension go. It is as if the relaxation happens automatically. That’s right. The relaxation response isn’t something that you force to happen, but something that you just let happen. Let’s see if you can do the same with the remainder of your body. To focus on the lower back, try to arch your lower back by dropping your head forward. Your back should roll into a smooth arc, tensing the lower back as you lean forward. Now relax the muscles by sitting up straight again. When you’ve done this you can move to your buttocks. Tighten your buttocks by pulling them together. You’ll feel yourself rising in your chair. Release the tension by sinking back into the chair . . . Then we’ll move down your legs, beginning with your thighs. While sitting, push your feet firmly into the floor to tighten your thigh muscles. Relax by stopping pushing . . . Now try to relax your calves. Lift your toes towards your shins to tighten your calf muscles. Now release the tension by dropping your toes again . . . Finally, with your feet, curl your toes down so that they are pressing against the floor. Now release by letting the feet straighten back to their normal position. I feel quite relaxed now. Are some places more relaxed than others? Yes, my neck and head still feels pretty tense, but my back and lower body feels better. That’s probably because the muscle groups where you notice the most tension need more work, so now that we’ve practiced each exercise, we’ll do them all in turn to relax your whole body. When you do this


Delivering empirically-supported treatments





on your own at home you’ll probably find it is best to do these exercises while sitting in a comfortable but straight-backed chair, with your feet flat on the floor, and hands resting in your lap. Sitting is preferable to lying down, otherwise you may find the urge to sleep may become overwhelming. Allow yourself around 1520 minutes in which you will not be disturbed. You may like to play soothing music, dim the lights, and draw the curtains. However, what we’ll do now is repeat the actions we’ve practiced, but in the way I’d like you to try at home. So you want me to do this for like homework? Yes, I want you to repeat this so that with practice you can get better at the progressive muscle relaxation and that you learn better to notice when you’re getting tense. Then you’ll be able to use some faster and more targeted relaxation exercises. That would be good, because I’m not sure I’ll always have 1520 minutes to relax. Although you won’t always have time, with more practice, you will get more benefits. We’ll talk about the practice a bit later, but for now let’s do a run through. I’d like you to sit back comfortably in the chair and close your eyes. Are you comfortable? Yes, I’m ready. OK. Well your body has a natural rhythm to it. You may have noticed that as you breathe in, you tend to tense. As you breathe out, you tend to relax. That’s why it is easiest to breathe in as you tense your muscles and breathe out as you release the tension. We’ll work through the same muscle groups as before but as we do each one I’d like you to do the following routine. First, as you’re breathing in, apply enough pressure to feel tension to the muscles so that they are about 75% tight. Hold the tension for 710 seconds and while you’re holding the tension try to breathe as easily as you can. After about 10 seconds, on the next breath out, let the tension go. Sometimes people find it good to mentally say the word relax as they breathe out. Once the tension has gone from the muscles, wait 10 seconds and then apply tension again or move on to the next area. I’ll talk you through this first time . . . That was good. I feel very heavy now. When you’ve finished relaxing, you will probably want to remain seated for a few minutes to enjoy the pleasant feeling. Try not to jump up too quickly as you may tense up again; you may even feel dizzy as your blood pressure drops when you relax. But while we’re sitting


Treating clients




here, what did you notice happened to your mind during the exercises? I found that my mind started to wander. That was a bit distressing and I forgot what I was supposed to be doing. That is perfectly normal. As you relax, your mind becomes less focused and it will wander. Recognize this sign of relaxation, because it is the opposite of being tense and stressed, when your mind is very stuck on one or two things. However, as you notice your mind has wandered off, gently bring your mind back to the exercises. Was there anything else you noticed? I’m not sure what you mean. Sometimes people find the bodily sensations of relaxation unusual and possibly worrying but whatever sensations you feel, it is important that you label them as part of the relaxation process. With practice, you’ll find that the sensations aren’t frightening and they become less noticeable over time. Bear in mind that physical relaxation is an art that takes persistence to master. Only a few people enjoy their first attempt; it is only with patient practice over a two month period that relaxation becomes a useful strategy in managing excess tension. I’m willing to give it a go, but does it always take so long? One of the main benefits of whole body relaxation is that you learn to recognize excess tension and replace it with relaxation. This means that taking time regularly to do the whole body relaxation is a good use of time even though it is time-consuming. However, when time is short, you can modify the normal progressive relaxation to a quick relaxation programme. Quick relaxation can be adapted to any situation. Although it may not bring the same degree of relaxation as the full 20 minutes of progressive muscles relaxation, it can be targeted at particular muscles. To relax quickly you need to identify which muscles are too tense, tense those muscles (as you breathe in) for 710 seconds, and then allow the muscles to relax (as you breathe out) for 710 seconds.

Summary In conclusion, clinical psychologists have an array of psychotherapies that have empirical support for a variety of conditions. However, there are psychological problems for which empirical support is still lacking and there are no doubt psychotherapies that do not yet have empirical support which will in time be



so identified. Thus, as a scientist-practitioner it is important to be familiar with empirically-supported treatments, and to continually evaluate the psychological literature to identify and become familiar with new treatments as they become supported (e.g., Emotion-focused therapy; Elliott et al., 2004 and Mindfulnessbased cognitive-behaviour therapy; Segal et al., 2002). Behaviour therapy (and variants such as Dialectical behaviour therapy; Linehan, 1993a, b), Cognitive therapies and Interpersonal psychotherapy (IPT; Klerman et al., 1984) represent some current treatments it is important to be familiar with. However, it is one thing to use an efficacious treatment, but another to be an effective clinician. Thus, even when using treatments with a known efficacy, it is necessary to evaluate the effectiveness in your setting by measuring and monitoring the progress of clients in therapy. Furthermore, with pressures to make treatment not only effective, but also efficient, there has been an increasing awareness that on the occasions when group treatment is equally or more effective than individual treatment, it is a valuable treatment option. Therefore, we will now turn to consider the delivery of group treatment.


Group treatment

Group-based interventions are available for almost every conceivable problem a person might experience over the course of a lifetime. A myriad of therapeutic groups facilitated by trained mental health professionals exist alongside an even greater number of self-help and mutual support groups (Dies, 1992). The mushrooming choices in the group-helping field over the last few decades, compounded by a chaotic proliferation of theoretical orientations with often limited empirical support and sometimes harmful consequences, resulted in much controversy and uncertainty (Scheidlinger, 2004, p. 266). Such a bewildering state of affairs is precisely the situation where a scientist-practitioner approach is helpful in separating the wheat from the chaff. For example, the long-term group therapy models derived from traditional psychoanalysis (e.g., Kutash & Wolf, 1993; Rutan, 1993) are incongruous with current health care systems that emphasize efficient, time-limited service delivery. In contrast, short-term group interventions based on a more substantial empirical foundation and designed to achieve relatively rapid relief from specific symptoms are increasingly popular in this era of accountability and cost-effectiveness (Dies, 1992). The latter are highly goal-oriented and use interpersonal interaction in small, carefully planned groups to effect change in individuals specifically selected for the purpose of ameliorating a circumscribed set of problems (Scheidlinger, 1994). The use of interpersonal interaction as a therapeutic tool in the here-and-now context of a group is an inherent advantage of group interventions. The presence of others provides opportunities for vicarious learning and the experience of universality, the relief felt from realizing that one’s concerns are not unique and are shared by others (Dies, 1992; Yalom, 1995). Moreover, by engaging with and helping others, patients learn to help themselves more effectively (Rose, 1993; Yalom, 1995). Finally, a group functions as a social microcosm that approximates the individual’s day-to-day reality more than a therapistpatient dyad does (Dies, 1992). Thus, patients can rehearse change strategies in the group and, after trying out those strategies in the real world, the group helps the


Selecting a treatment programme

patients evaluate the outcomes (Rose, 1993). This iterative rehearsal in group and community increases the probability that learning will generalize beyond the immediate context of treatment. Given the unique therapeutic advantages and cost-effectiveness of group interventions compared to dyadic sessions, how does a therapist go about selecting, modifying, or developing a group treatment programme that meets the standards of science-informed practice and accountability in patient care?

Selecting a treatment programme The first step in selecting a group programme is to determine if there is an empirically validated treatment manual for the particular problem that is targeted by the intervention (see Figure 6.1). For example, excellent treatment manuals with step-by-step clinician guides and ready-to-use patient materials are available for group treatments of social phobia (Andrews et al., 2003) and obesity (Cooper et al., 2003). But what if such detailed manuals are not yet available? Consider the example of smoking cessation. Until the publication of a comprehensive Tobacco Dependence Treatment Handbook in 2003 (Abrams et al.), that included a chapter describing an eight-session behavioural treatment programme for smoking cessation, practitioners had to develop their own programme based on their knowledge of the literature. In the case of smoking cessation, this process was greatly facilitated by clinical practice guidelines, which had been derived from systematic reviews of treatment approaches and were disseminated by the end of the last millennium (Fiore et al., 2000; Miller & Wood, 2002; Raw et al., 1998; West et al., 2000). Practice guidelines identify the treatment strategies, formats, and parameters for which there has been sufficient evidence of their effectiveness. This may include recommendations about what treatment strategies to include or what the optimal number sessions is, but the clinician is still left with the nuts and bolts of translating that information into a coherent treatment programme. In the absence of clinical practice guidelines, the individual clinician has the additional task of critically distilling from the literature what a smoking cessation programme should entail and how it should be structured. Alternatively, if an available treatment manual focuses primarily on behavioural strategies (e.g., Brown, 2003), but the literature suggests that a combination of behavioural, cognitive and pharmacological approaches outperforms either treatment alone, the clinician may want to modify the existing programme by incorporating a pharmacotherapy component (e.g., Goldstein, 2003) and other relevant principles of treating addictive behaviours (e.g., Miller & Heather, 1998), as well as cognitive-behavioural strategies relevant to group


Group treatment

Figure 6.1.

The process of integrating individual case formulation and treatment within scienceinformed, group-based interventions for the example of nicotine dependence

treatments more generally (e.g., Rose, 1993). In either case, the onus is on the clinician to evaluate if this newly designed or modified treatment programme produces outcomes that are comparable to those published in the literature (see ‘‘Evaluation & Accountability’’ box in Figure 6.1). For example, the recent literature on smoking cessation treatment recommends the use of biological markers such as carbon monoxide (CO) to infer strength of habit from nicotine levels in the patient’s body (Niaura & Shadal, 2003), to provide feedback on initial CO levels to increase motivation for change, and to assess post-cessation CO levels to demonstrate the positive physical health consequences of quitting (Emmons, 2003). From these general recommendations, it is not clear how closely changes in CO levels would correspond to changes in smoking levels. If CO levels are measured weekly, but are not sensitive enough to reflect small reductions in average number of cigarettes smoked per day over the previous week, then lack of change in the true biological index undermines the boost in self-efficacy patients typically experience when realizing that the effort of executing small, planned, behavioural changes in daily routines


Assessment and pre-group orientation

has resulted in immediate, tangible reductions in their cigarette intake. If, on the other hand, changes in CO levels closely parallel those gradual reductions in daily cigarette intake, they can serve as a powerful motivator to stay committed to the ultimate goal of becoming smoke-free. Given that the available treatment handbook does not offer explicit guidance on how to resolve the above issue, a scientist-practitioner would act as a local clinical scientist (Stricker & Trierweiler, 1995) and evaluate the results of the decision to use weekly CO monitoring. We will return to this example in our monitoring and evaluating progress and outcomes section below, but first, we will describe what factors need to be considered in selecting patients for a group, and how the process of individual case formulation and treatment is modified and enriched within a group-based intervention. Selecting patients for a group In goal-oriented groups where the emphasis is on support and reduction of a specific set of symptoms over a short period of time, the composition of the group by definition will be relatively homogenous in terms of symptomatic complaints. One advantage of such homogeneous groups is that their concerns and goals for treatment are closely aligned, and therefore they can be quickly moved into a working mode by an active and facilitative therapist (Klein, 1993). The manageable size of groups ranges from 4 to 12 members, with 8 members usually regarded as the ideal number (Klein, 1993; Yalom, 1995). In order to approximate this ideal number, it is important to consider attrition rates. These can range from 17 to 57 percent (Yalom, 1995). It is therefore advisable to start with a group that is about 20 percent larger than the targeted size, so that the predictable dropouts of two or three members early in treatment do not affect the critical number needed for interactive group processes to occur. The principal consideration in selecting individuals for a group is that they are able and willing to participate in the primary task of the group (Yalom, 1995). That is, they must be available regularly over a specified period of time, have a desire for change, and have the capacity to tolerate a group setting. Beyond these basic inclusion and exclusion criteria, the choice of patients is often determined by expedience, the availability of suitable candidates, and the need to respond flexibly to referral requests, especially when working in multidisciplinary settings. Assessment and pre-group orientation In group-based interventions, the process of linking assessment data and case formulation to treatment planning involves two components. One is the


Group treatment

individual case formulation that follows from the synthesis and integration of the assessment information regarding each patient’s history and circumstances with respect to the presenting problem. The other component is a group formulation (see Figure 6.1). That is, treatment planning is also informed by the unique constellation of individual group members’ characteristics and circumstances. The aim is to anticipate and plan for likely patterns of group interactions and processes that can either facilitate or hinder individual patients’ treatment goals. For example, some of the participants in a smoking cessation group may have been prompted by similar motives to join the group, such as worry about ongoing medical problems that are caused or exacerbated by smoking, or concern about exposing their children to the harmful effects of secondary smoke, or embarrassment toward work colleagues for engaging in a stigmatized behaviour. This information can be used at the start of the group to build cohesion and mutual support among group members. Likewise, some group members may report similar barriers to their aspirations of becoming smoke-free, such as high levels of stress, worry about weight gain following cessation, or significant others who are smoking in their presence. The group formulation determines which of these potential impediments to treatment success are particularly relevant in a given group, and thus influences the selection and timing of curricular elements during treatment planning (Rose, 1993). In addition to adjusting aspects of the treatment delivery based on the group’s pattern of factors specifically related to symptom presentation (for our example, this would include a detailed smoking history, level of dependence, craving, previous quit attempts, readiness to quit, etc.), group formulation and treatment planning are informed also by more general information about patient characteristics obtained during assessment. For example, patients may have other medical or psychiatric conditions that they may not wish to reveal in front of other group members, and that are not critical to address within the group’s explicit purposes. Equipped with this knowledge, the group facilitators can plan their sessions accordingly and skillfully manoeuvre around such confidential issues to protect individual members from unintentional disclosure and embarrassment. Other general assessment information that is particularly relevant to the planning of groups includes pre-existing relationships between group members and interpersonal styles. It is not uncommon that problemfocused groups (e.g., smoking cessation, weight management, fear of flying) are attended by individuals jointly with a partner or a friend. The dynamic between such dyads within the group may require special attention and management. Similarly, considering which members were particularly talkative or timid during assessment can be helpful for facilitating group interactions while ensuring that all members receive equal attention. Finally, assessment yields a wealth of


Assessment and pre-group orientation

information on the particular personal meanings, circumstances, and events that individual patients associate with their struggles and tribulations with the presenting problem. The planned use of these patient-generated examples at the start of the group is an effective way to personalize explanations of the rationale, principles and strategies underlying the treatment programme. Besides the primary assessment function of informing individual case and group formulations as a basis for treatment planning, it is also essential that the therapist uses the assessment session to prepare the patient for the group and start the process of building a therapeutic alliance. Drawing on Yalom (1995) and others (Klein, 1993; Salvendy, 1993), we recommend the following preparatory tasks to be covered with a patient prior to entrance into the group. Enlist patients as informed allies

Explain the rationale underlying the treatment programme. For a smoking cessation group, this would involve an explanation that nicotine addiction is not only maintained by the reinforcing pharmacological effects of nicotine on the brain, but is also powerfully driven by the behavioural aspects of the addiction. Consequently, both the pharmacological and behavioural components of this addiction need to be addressed in treatment. This is why patients need to hit the deck running and start from the first session implementing the behavioural strategies taught in that session, which are later complemented by chemical treatments such as nicotine patches. Offer guidelines about how to best participate in the group

This will of course vary according to the purpose of the group, although some aspects are common to most groups. Emphasize that group therapy is hard work and that patients are expected to take responsibility for their treatment progress. Stress the importance of punctual and regular attendance. Explain that they will benefit the most by actively engaging with the programme and the other members. Introduce the mantra of treatment success, that is, change comes from doing things differently, and that they need to be prepared to do lots of things differently every day once treatment has commenced. Encourage them to provide support to fellow group members. Clarify format and duration of the programme

Provide information on what to expect in the first session and beyond. If appropriate, preview the time-frame of critical treatment components and follow-up sessions. For example, in a smoking cessation group, patients might be informed about the relative timing of behavioural strategies, quit day, and nicotine replacement therapy. Explain the nature of between-session work with


Group treatment

the help of patient handouts, worksheets, and goal-attainment monitoring materials. Describe the session structure and any key staff (co-therapist, supervisor, nutritionist, social worker, etc.) that may be part of the treatment team. Clarity on organization, structure, and procedures of the group helps to allay anticipatory anxiety that stems from uncertainty and misconceptions about group therapy. Set ground rules

When it comes to setting rules for groups, less is more! Too many rules constrain the very processes by which group interactions add value over the narrower bandwidth inherent in one-on-one communications. Yet, two simple ground rules are essential for groups to fulfil their therapeutic potential. First, what occurs in the group remains confidential. This is not to say that patients are not permitted to share any of their experiences and the benefits they derived from them with someone outside the group. After all, many clients join a group on the recommendation from a family member, friend, or colleague, who was satisfied with attending the same or a similar group in the past. What must remain strictly confidential is any identifying information that could be linked to a person, place or event associated with the other members of the group. Second, time and attention in the group are shared equally. Patients are asked to be active participants while being mindful of the needs and different views of other members in the group. Anticipate frustrations and disappointments along the way

Patients often develop feelings of frustration or annoyance with the therapist when realizing early during the group programme that quick fixes are not forthcoming and that the responsibility for ‘‘doing things differently’’ ultimately rests with each patient. Similarly, seeing some group members progress at a much faster rate, or another group member relapse after considerable treatment gain, can be upsetting and undermine motivation. It is important to communicate to patients from the outset that there are different paths to achieving the treatment goals and that setbacks are normal. Challenge the patient’s perception of setbacks as failures and reframe setbacks as important opportunities for learning to do better the next time. Instil faith in the programme and optimism about the outcome

One of the great benefits of adhering to a science-informed approach to practice is that even the novice group therapist can, with utmost confidence, assure patients that the programme works and has helped many patients to get better. Especially if the therapist can refer to recent outcome data collected from a previous group


Getting the group under way

conducted in the same clinical setting (see Figure 6.1 for feedback loop from ‘‘Evaluation & Accountability’’ to ‘‘Clinical Training & Experience’’), patients will react to this information with hope and optimism about their own chances for success. This will go a long way in getting patients ‘‘on board’’ with the rationale for the treatment and the methods to implement it. Consider adaptations of typical practice to the particular group

Not all groups are equivalent and the nature of the presenting problem can affect the nature of the interactions and the manner in which the group is conducted. For example, in our social phobia group programme we begin the initial session with clients arranged in a semi-circle facing the therapists in order to reduce the discomfort, but move to a circle with therapists at either end of the room. The anxiety generating effects of these changes and the anxiety reduction within sessions are then discussed as part of therapy. Likewise, we do not begin by asking people with social phobia to discuss their problems, but we ask them to write comments on paper which are then put in a bowl. The comments are then read out and discussed, but because they are anonymous, the anxiety generated is less intense. In other group formats, such as working with patients with Borderline personality disorder (Linehan, 1993a), patients are informed how the group treatment is to complement the individual treatment and which topics are for group discussion.

Getting the group under way Yalom (1995) observed that the first session is invariably a success, because both patients and novice therapists tend to ‘‘anticipate it with such dread that they are always relieved by the actual event’’ (p. 294). Although this should be reassuring to the novice group therapist, it cannot be overemphasized how important it is to get a group off to a good start. Given the brevity of many contemporary evidence-based group programmes (i.e., typically not exceeding 1012 sessions), the first session constitutes an important anchoring function, a point of departure where patients are coached to rapidly embrace the rationale and treatment principles that are at the very heart of what makes the programme evidence-based and hence successful. A directive and purposive approach is essential. A first meeting typically begins with a brief restatement of the ground rules, some housekeeping issues (when are breaks, where is the restroom, etc.), and an opportunity for group members to introduce themselves and their reasons for joining the group. Because generally these reasons are already known to the


Group treatment

therapist from the assessment interviews, the therapist can use this knowledge to strategically plan a tentative outline of whom to draw in to the interaction during this introductory phase on what occasions, so as to initiate the process of sharing and bonding among members. Thus, while this interaction may appear quite conversational and free-flowing to the patients, the therapist is hard at work and can guide the process into fairly predictable patterns with the aim to accelerate the establishment of group behaviour that is instrumental to change and sets the stage for the working phase of the session. Following the introductions, therapists will review the rationale of the programme, the strategies that will help patients change, and the reasons why these strategies will work for them! In other words, here is where scientist-practitioners give all the secrets of the profession away. They demystify the process of treatment and make it clear that it is the patients’ responsibility to engage in the change strategies that they learn and practice in the group, if they want to experience change. Change does not happen from doing things the same, change happens from doing things differently. Therefore, while therapists need to communicate warm and empathetic understanding of the patients’ concerns and frustrations stemming from the presenting problem, it is equally important to communicate in a firm and directive manner that patients need to begin acting on what they learn in group from day one. For example, in the context of a smoking cessation group, this involves the introduction of a menu of options of change strategies, from which each patient must select at least one or two strategies to be implemented between the first and second group sessions. In addition to immediately engaging in active change behaviours, patients need to be educated about the benefits they can expect from monitoring and evaluating the outcomes of their efforts.

Monitoring and evaluating progress and outcomes Just as treatment planning in group-based interventions is informed by an integration of individual case data within the overall group pattern, so is treatment monitoring and outcome evaluation (see Figure 6.1). While group programmes allow for flexibility in how and at what pace individual members progress toward the treatment aims, there are often phases or milestones that provide a common threat and that serve to gauge individual members’ progress toward goal attainment relative to the change trajectory of the group as a whole. For example, in the first phase of a smoking cessation group, most members will be successful in gradually reducing their daily intake of cigarettes by increasingly adopting a variety of behavioural change strategies. This is followed by a


Monitoring and evaluating progress and outcomes

Figure 6.2.

Change trajectories of two patients from a smoking cessation group

preparation phase for planning a quit day and the start of nicotine replacement therapy to ease withdrawal distress after becoming smoke-free. The last phase and follow-up assist with reducing relapse risk and adjusting to the significant lifestyle changes associated with becoming a non-smoker. As illustrated in Figure 6.2, two smokers from the same group can have different trajectories


Group treatment

toward becoming smoke-free. Whereas Patient A showed a gradual progression toward goal attainment and was smoke-free by Week 9, Patient B experienced some significant health problems during the early weeks of the group which precluded her from attending for a couple of weeks. With the help of betweensession materials supplied by the therapists, and by redoubling her motivation and effort upon rejoining the group, this patient was determined to catch up with the group and hence showed a much steeper trajectory toward successful goal attainment than Patient A did. As shown in Figure 6.1, treatment implementation is continually adjusted as a function of progress achieved by individual members within the parameters of the group’s progress overall. In the case of Patient B in Figure 6.2, the lack of progress early on could be attributed to external factors associated with stressful medical procedures that interfered with her ability to fully adhere to the group’s treatment plan. For other patients, lack of progress may be indicative of internal factors, such as ambivalent attitudes toward change or low motivation. In that case, the timing and intensity of programme components dealing with motivational interviewing techniques can be adjusted accordingly. At the same time, the group therapist can use the positive example set by Patient A, who started out with one of the highest levels of nicotine dependence and daily cigarette intake within the group (i.e., 60 per day), as tangible evidence that engaging with the treatment process leads to goal attainment. However, for therapists to fully exploit these opportunities for vicarious learning within groups, they need to wear a scientist-practitioner’s hat. They need to be committed to regular, systematic evaluation and documentation of the group’s progress. Likewise, for patients to fully harness the benefits of making the link between implementation of the treatment strategies learned in group and the resulting gradual changes toward goal attainment, they first must be aware of these changes. Often these changes will be subtle at first and become obvious only when viewed as a trend over repeated measurements. It is therefore essential to provide group members with regular, easy-to-follow feedback on critical outcome measures such as those illustrated in Figure 6.2. Evaluation of individual and group progress with the help of clear graphs should be a routine component of any group treatment programme (Woody et al., 2003). The value of systematic documentation of group progress and outcomes is threefold. Firstly, routine examination of group progress data stimulates vicarious learning and mutual support among group members. Consider the pattern of treatment progress for five members of a smoking cessation group in Figure 6.3. Note that all patients show the predicted gradual decline in daily cigarette intake over the first 6 weeks, with Patient C showing the steepest decline


Monitoring and evaluating progress and outcomes

Figure 6.3.

Pattern of treatment progress for five patients in a smoking cessation group

(over 50% reduction) after initially starting out with the highest level of cigarette use. Because of her excellent progress, her determined and upbeat attitude, and her strong encouragement of others in the group, Patient C had become somewhat of a role model. After she experienced a severe relapse in Week 7, three things were particularly instrumental in getting her to re-commit to her treatment goal. One was a brief, caring phone call by the group therapist following her absence in Week 7 to encourage her to re-join the group the following week. Another was the non-judgemental, warm, supportive reaction by her fellow group members following Patient C’s return in Week 8. But, particularly important to Patient C in overcoming this setback, was the compelling evidence of her successful steady progress prior to her relapse, which reinforced her belief that she had the capacity to succeed at this difficult task. Equally important was the evidence following her decision to re-commit to treatment, which confirmed to her that she had overcome the setback and consolidated the treatment gains achieved prior to the relapse. Although Patient C was not smoke-free by the end of the last group session, she succeeded in becoming smoke-free prior to the follow-up session two months later. Secondly, systematically accounting for group progress and outcomes is valuable because accurate feedback on partial improvements that fall short of the ideal outcome can still be therapeutically meaningful. For example, smokers who reduce their daily cigarette intake by at least 50 percent (see Patients A and B at follow-up in Figure 6.3), have an increased chance of becoming smoke-free


Group treatment

in the future (Hughes, 2000) and have reduced their exposure to harmful levels of carbon monoxide (CO) in their body (see Figure 6.2). Thirdly, accurate documentation of successful group treatment outcomes adds value to any services offered in a competitive healthcare market. This is especially critical if the clinician had to newly design or modify a treatment programme. Recall the earlier example of incorporating the monitoring of CO readings as an outcome measure into a smoking cessation programme. If CO readings lacked sensitivity to accurately mirror small, gradual changes in smoking behaviour, then their addition to the treatment protocol could undermine motivation to continue with the behavioural strategies. The scientist-practitioner can use replication of positive outcomes across clients within a group (e.g., see the close correspondence between self-reported behavioural changes and CO reading for Patients A and B in Figure 6.2), followed by replication of this pattern across subsequent groups, to build confidence that the introduction or modification of a new treatment component was useful in improving treatment outcomes. If these treatment outcomes exceed the average success rates of smoking cessation treatments published in the literature, the clinician can be confident that the newly refined treatment programme is providing value for money. Thus, programme evaluation is central to the activity of a science-informed practice and this will be the focus of the following chapter.


Programme evaluation

The concept of ongoing quality improvement is inherent in the science-informed approach to clinical practice. The evaluation skills needed to ensure that treatment programmes and services are delivered in line with best practice standards and, as a whole, reliably achieve clinically meaningful improvements in patient health and satisfaction, are as important to acquire for clinical psychologists as the therapeutic skills involved in the actual treatment of individual patients. The role of psychologists as healthcare providers in a competitive healthcare market (see also Chapter 13) makes it imperative that empiricallybased outcome evaluation is not only conducted at the level of the individual patient, but is routinely extended to outcome evaluation at the aggregate level of the service provider or agency (see Figure 7.1). Clinical psychologists by virtue of their combined training in research and clinical practice already have a solid grounding in research methodology and extensive experience in data management and analysis. This distinguishes them from many other healthcare providers and places them in a good position to make valuable contributions to addressing programme evaluation needs within their employment settings. However, programme evaluation involves more than competent data collection and analysis. In addition to data management skills, good evaluators need to develop good negotiation and communication skills (Owen & Rogers, 1999). Whereas research findings are instrumental in drawing conclusions that generalize to a broader context of a discipline or area of investigation, evaluation findings serve to inform decisions about specific aspects of a programme or policy within a local context. Hence, the conclusions that evaluators draw from quantitative and qualitative data will be influenced by the position held by various stakeholders. These may include consumers, policy makers, funding bodies, and staff and management of the respective agency (see Figure 7.1). For example, evaluation data may be used to demonstrate that service provision achieves stated outcomes and is cost-effective, to account for the resources spent on developing and implementing a new service, to monitor


Programme evaluation

Figure 7.1.

Programme evaluation extends routine evaluation of individual patient outcomes to evaluation of outcomes, procedures and policies at the level of the service setting

quality of care, to articulate the value of particular services to management and funding bodies, or to market services to consumers. In order to achieve these goals, the views and values of relevant stakeholders need to be considered. Good negotiation skills in the planning stage of an evaluation are essential to clarify and endorse the purpose of the evaluation, and to maximize the quality and utility of the data to be collected. Good communication skills are needed because evaluation data need to be translated into effective recommendations. Effective recommendations are those that are specific, realistic in scope, easily translated into action, and mindful of any constraints within the organizational environment that might hinder their full implementation (Sonnichsen, 1994). Clinical psychology trainees typically experience two modes of skills training in programme evaluation: didactic teaching including practical experience in conducting small-scale evaluation projects, and modelling via exposure to and participation in ongoing programme evaluation activities within their training clinic and community placements. By embracing evaluation as a continuous


Five basic steps of programme evaluation

learning process of asking questions, reflecting on the answers to these questions, and modifying actions and strategies in light of those answers, trainees learn to be committed to a process of continual improvement that forms the basis of accountability and good practice. As shown in Figure 7.1, members of the agency staff may be the direct beneficiaries of evaluation findings. To the extent that these findings are incorporated in continuing education and training of staff, programme evaluation adds to the wealth of clinical experience that practitioners bring to bear in treatment planning and implementation. There is an enormous diversity in approaches to programme evaluation (Wholey et al., 1994), and the scope of many evaluation designs and purposes extends well beyond the local clinical context in which practitioners typically engage in programme evaluation. These more systemic evaluation projects are conducted by teams of professional evaluation contractors and are not the focus of this chapter. In this chapter, we introduce trainees to a few basic steps of programme evaluation that are common to the sort of evaluation projects that practitioners are likely to use in their respective local clinical setting on a routine basis. We will illustrate these steps with examples drawn from evaluation projects that clinical psychology trainees may encounter in their own clinical training setting. Five basic steps of programme evaluation 1 Asking the right questions

The questions that form the impetus for a programme evaluation can be categorized according to their primary purpose. Owen and Rogers (1999) identify five conceptual categories. Proactive evaluation is conducted prior to the design and implementation of a treatment or programme. Questions addressed in proactive evaluation might include: Is there a need for a particular treatment or programme? (e.g., should a women’s health centre offer a smoking cessation programme aimed at pregnant women? Is there a need for offering clinical psychology trainees practicum experience in rural and remote settings?). What does the relevant literature or professional experience tell us about the problems and benefits of introducing a particular service? Have there been previous attempts to address this need or problem? Are there external sources or agencies that could contribute expertise and solutions to problems in implementing a programme? Clarificative evaluation examines the internal structure of a programme or policy. It clarifies how the programme’s elements and activities link to intended outcomes. Data will need to be collected that might address questions such as the following: What are the intended outcomes of the programme? What does the


Programme evaluation

programme do to achieve those outcomes? Is the rationale for certain aspects of the programme plausible? One example of clarificative evaluation that clinical psychology students may experience with respect to their own training programme is accreditation. Accreditation aims to certify that the structure, components, and procedural guidelines of a programme are of a standard that instils confidence that the programme can deliver what it intends to deliver. Unlike clarificative evaluation, which is concerned with design and logic of a programme, interactive evaluation is concerned with implementation of a programme or its components. This form of evaluation is formative in nature and is particularly appropriate for the purpose of ongoing quality improvement. Questions asked in an interactive evaluation might include: Are there ways in which the delivery of services can be changed to make it more effective? Are therapists implementing agency practice guidelines? Do programme activities or innovative approaches make a difference? Are there changes in the type of patients and problems that present at the clinic? Are the skills taught in a training clinic up to scratch in meeting the demands of current and projected workplace requirements? Monitoring evaluation aims to provide quantitative and qualitative information at regular intervals to gauge if performance indicators are in line with specified programme targets and implementation is carried out as intended. Questions asked during monitoring evaluation might include: How do patient outcome and satisfaction indices compare with the previous year? Are the resources available to therapists sufficient to meet current and projected trends in service delivery and patient needs? What is the average length of treatment provided by therapists? What is the rate at which clinical psychology trainees accumulate supervised client-contact hours? This type of evaluation often uses outcome monitoring data. Unlike programme evaluation, outcome monitoring itself is not explanatory, but simply generates routine reports of programme results, which are then available for periodic evaluation and interpretation. Thus, results-oriented monitoring generates the proof needed to satisfy the accountability mandate (Affholter, 1994). In addition, outcome monitoring facilitates the early detection and correction of problems as well as the timely identification of opportunities for innovation and performance improvement (Affholter, 1994). Finally, impact evaluation assesses the attainment of intended outcomes against specified criteria or outcome indicators. This category of evaluation is often summative in nature and may assist in decisions to scale back, terminate, continue, or expand certain services or programmes. Impact evaluation may also include an analysis of unintended programme outcomes and of the integrity of implementation. Questions addressed in impact


Five basic steps of programme evaluation

evaluation might include: Do patients receiving treatment in a training clinic achieve reliable and meaningful improvements in psychiatric symptoms and well-being? Are patients showing improvement in a timely and cost-effective manner? How long does it take graduates from a training programme in clinical psychology to find employment in their chosen field? Once a set of critical evaluation questions has been determined that reflects the primary purpose and scope of the evaluation, the next step is to develop an evaluation plan. 2 Developing an evaluation plan

The second step of programme evaluation involves planning how to find answers to the critical questions agreed upon in the first step. Several issues need to be considered when negotiating an evaluation plan (Owen & Rogers, 1999). One consideration is who the recipients and users of the information are going to be. For example, if the question is how long it takes to find employment after graduation from a clinical psychology training programme, information will be primarily used by (a) current students from the programme for career planning, (b) future applicants to the programme for weighing the pros and cons of entering the programme, (c) potential employers for gauging the quality of graduates from the programme, and (d) programme directors for promoting the quality of programme graduates to employers and for advertising the strengths of the programme to prospective quality applicants. A second consideration is what personnel and material resources are available to conduct the evaluation project. All evaluations are subject to resource and time constraints which determine the extent of information gathering, the complexity and sophistication of data management, and the range of dissemination strategies. If the people who deliver a programme are also part of the evaluation team, then time and resources need to be made available for the evaluation tasks. These tasks should not present an additional burden on normal workload and should therefore be integrated within the routine demands of day-to-day programme activities. A third consideration in developing an evaluation plan is selecting the data collection and management strategies that are most appropriate for each evaluation question. It is important to bear in mind that the level of data analytic complexity should not exceed the sophistication of the intended audience. Clarity and utility are paramount. To answer the question of how long it takes for graduates to find employment, a brief survey could be designed that examines not only time taken to secure the first job, but also provides further informative details such as number of job interviews relative to job offers, success in obtaining most preferred positions, duration of first contracts, starting income


Programme evaluation

level, time taken to progress to more senior or permanent positions and/or higher income levels. If data on prompt employment of graduates are not only of interest as an index of recent training success, but are also viewed as a performance target to be maintained in the future, data gathering may also require the simultaneous elicitation of critical feedback. Thus, the plan for data collection may include some open-ended forms of information gathering where respondents can identify areas for improvement in training, so that future graduates are kept abreast of evolving trends in knowledge and skills expected of their profession. In addition, the evaluation plan would articulate sampling strategies and may identify potential external resources that could aid in data collection. For example, a survey of recent psychology graduates could be mailed with the help of existing mailing lists kept by the university alumni services and could be included in their regular mailings at no cost to the evaluators. Finally, the data management component of the evaluation plan must specify how data will be processed and analyzed. A fourth aspect in developing an evaluation plan concerns the strategies that will be used to disseminate the outcomes of the evaluation. This involves determining when and in what format reporting will take place, and what kind of results, conclusions, and recommendations will be included. Finally, an evaluation plan must estimate the costs associated with carrying out the plan. The constraints imposed by the size of the budget and the amount of available resources have a direct impact on the timeline that can be set for achieving the various phases of the evaluation project. The timeline may also be constrained by any ethical issues that need to be addressed before and during the implementation of the evaluation. How these ethical issues will be handled need to be made explicit in the evaluation plan. After completion of the evaluation plan, the data gathering phase commences. 3 Collecting and analyzing data to produce findings

The third step of programme evaluation produces evaluation findings. These findings link the evaluation questions to answers that are then disseminated to relevant stakeholders (see Figure 7.2). The key tasks during the evidence gathering phase involve selecting and gaining access to the most appropriate sources of data, and then obtaining the data. Sources may include existing records and documents, as well as individuals who can either provide relevant information directly or are the gatekeepers of the information required. One of the most important tasks of data management is the maintenance of a reliable database. Clinical psychologists trained within a science-informed approach to clinical practice are usually very experienced in conducting and supervising the tasks involved in data reduction and analysis. Interpretation of the results of


Five basic steps of programme evaluation

Figure 7.2.

The collection, management, analysis and interpretation of data link the evaluation questions to answers for utilization by relevant stakeholders

the analyses must, of course, be grounded in the evidence, but in programme evaluation it is also important to ensure that the interpretation of evaluation findings reflects the diversity of viewpoints by different stakeholders. Are the conclusions based on a valid and balanced reflection of the evidence? Are there any limitations of the evaluation findings? Could these limitations have different implications for different stakeholders? It is essential to remember that evaluation conclusions must win the support of relevant stakeholder if they are to be utilized and lead to action.

4 Translating findings into recommendations for action

The fourth step of programme evaluation produces recommendations based on the judgements and interpretations derived from the evaluation findings. All recommendations have the purpose of influencing organizational decisionmaking. They may be used to justify decisions already made or, more typically, they inform and shape decisions about courses of action intended to bring about organizational change (Owen & Rogers, 1999). Whereas the first three steps of evaluation look backward and examine the status quo, the recommendations developed in the fourth step as part of the written evaluation report are designed to think forward. They are prescriptive and present solutions to problems, which in turn provide the impetus for organizational debate and action (Sonnichsen, 1994). As such, writing good recommendations is the most pivotal component


Programme evaluation

of the final evaluation report if the evaluation effort is to bring about desirable change. Effective recommendations are characterized by several basic qualities (Sonnichsen, 1994). Foremost, recommendations must be delivered in a timely manner. Evaluation outcomes that are not available when they are needed are of little value to decision makers. Recommendations must also be realistic. Unless factors that might constrain the implementation of a recommendation are carefully considered, the recommendation may be viewed as impractical and hence is likely to be ignored. For the same reason, it is wise to avoid recommending changes that are so fundamental that they threaten values perceived by staff to be core aspects of the programme under evaluation. Such radical proposals for change are bound to meet with strong resistance and hence have little chance of being implemented successfully. In addition, care must be taken to direct each recommendation to the appropriate persons who are in the position to act on and oversee its implementation. Otherwise, recommendations will collect dust and get bogged down in organizational inertia. Good recommendations are simple and specific. Each should focus on only one issue and make explicit what tasks are to be executed by whom to ensure its implementation. Finally, the link between each recommendation and the empirical findings that underlie it must be clear. This will enhance the credibility of the recommendations and thereby their potential for acceptance and implementation. The written recommendations can be seen as the ultimate product delivered by the programme evaluators. Because they are embedded in the final evaluation report, it is important that evaluators present their final report in a way that makes it easy for readers to understand the evidence behind a recommendation, the benefits of implementing it, and how to get there. If recommendations are entombed in a thick, unwieldy report, they are likely to remain unread, and hence cannot have an impact on ongoing quality improvement of service delivery. Therefore, they need to be displayed prominently in the final report. Sometimes adding page references to the relevant sections of the report can make it easier for the readers to find sections of interest. Although the specific content, structure and format of an evaluation report will depend on the target audiences and the guidelines imposed by funding bodies, most evaluation reports present upfront a brief section with an executive summary. This summary provides a brief overview of the evaluation aims, methods, and key findings, and highlights the recommendations that follow from these findings. The remainder of the report typically contains a more detailed introduction to the evaluation, a review of the literature, a description of the methodology, a succinct report of outcomes, and a discussion of the interpretations and judgements leading to


Five basic steps of programme evaluation

the recommendations. Further details are usually relegated to appendices in the form of tables or figures. Even if great care has been invested in writing effective recommendations and presenting them in a way that they are quick to absorb and easy to understand by the stakeholders, this is not a guarantee that they will be adopted and lead to change. It may be desirable and possible, especially within local clinical settings where interactive forms of evaluations are often useful, for evaluators to be also actively involved in facilitating the transition from recommendations for action to the actual initiation and follow-up of the recommended changes. 5 Advocating and promoting change

Evaluation findings produce recommendations, but recommendations do not always influence organizational decision making. As Sonnichsen (1994) noted, ‘‘some evaluators labour under the delusion that elegant methodologies, eloquent reports, and scientific neutrality are sufficient qualities to ensure that evaluation results will be used’’ (p. 535). Non-use of recommendations may in part be due to the judgemental nature of evaluation. If recommendations for change are perceived as criticism and elicit defensive reactions, they are not likely to be universally met with enthusiasm. For recommendations to lead to change, the evaluation process must include a plan and strategies for actively promoting that change. The onus is on the evaluators to market the benefits relative to the perceived risks of changing, while highlighting the risks of not changing. In clinical settings, failure to act on reliable and valid evaluation outcomes is costly and harmful, because it leads to overuse of unhelpful care and underuse of effective care (Berwick, 2003). Thus, the translation of evaluation recommendations into practice must be actively promoted as a value-adding organizational enterprise. One important strategy of promoting recommended changes is to not wait for audiences to request information, but to actively seek opportunities for communicating key findings regularly and frequently in a variety of formats (Hendricks, 1994). The consequences of recommended changes may impact differently on individuals or groups within the provider organization. Thus, readiness for change can be enhanced if the recommendations are as compatible as possible with the values, beliefs, past experiences and current needs of the various stakeholders (Berwick, 2003). When promoting change, simplify! Audiences tend to be busy and are not so much interested in general information than in the bottom line. They want guidance on what they are expected to do differently, and reassurance on how the benefits of doing things differently outweigh the costs of doing things the same. This means that delivering recommendation only as part of a lengthy evaluation report may be insufficient


Programme evaluation

to initiate and sustain change. Personal, concise briefings tailored to select individuals or small audiences, accompanied by the use of effective visual aids and handouts, and delivered with ample opportunities for questions, comments and discussion, provide additional momentum for translating recommendations into action (Hendricks, 1994). Another important strategy for promoting recommended changes is to form a team of individuals and invest them with sufficient power to lead the change effort (Owens & Rogers, 1999). The primary task of such at team is to mould the various recommendations into a coherent vision, and to communicate that vision synergistically to all stakeholders. The efforts of this team must be supported by administrators in the form of structures that facilitate the changes and remove potential obstacles to implementing them. Finally, the adoption of recommended changes can be greatly facilitated if one allows for, and even encourages, local adaptation of the recommended courses of action. Recommendations will have their greatest impact if changes are not only adopted locally, but also adapted locally (Berwick, 2003). That is, programme innovators must guard against the tendency to be too rigid in their insistence on exact replication of the recommended courses of action. Innovations and improvements are remarkably robust to modifications suggested by those who are ultimately responsible for translating them into the reality of practice. In fact, locally ‘‘owned’’ adaptation is a critical and nearly universal property of successful dissemination of novel ideas and practices (Berwick, 2003). Such fertile reflection on the process, findings and recommendations of an evaluation project is the essence of continuing quality improvement. It enhances capacity building by developing a culture of reflective practice and quality assurance. Moreover, local adaptation of evaluation outcomes stimulates the generation of new critical questions within the group of key stakeholders, which in turn set in motion the wheels of subsequent rounds of programme evaluation. Good practice is reflective practice! Programme evaluation is the tool to ensure that reflective practice is happening. In sum, empirically-based outcome evaluation is the foundation of accountable clinical practice, both at the level of the individual patient and at the aggregate level of the service provider or agency. The mandate of accountability pertains to both the products of treatment and the procedures used to achieve these products. Therefore, delivering a high quality product requires good case management skills. In the next chapter, we will describe the key tasks involved in conscientiously managing all aspects of patient care from the first contact to termination of the therapeutic relationship.


Case management

The effective, efficient and ethical delivery of psychological services requires good case management skills. Case management involves the integration of three interrelated tasks. In addition to the fundamental conceptual task of integrating evidence-based practice with practice-based evidence, which is the essence of the science-informed approach to clinical practice, treatment involves management tasks and documentation tasks. In this chapter, we will outline the key management and documentation tasks associated with specific phases of the treatment process, as well as some tasks that are important at all stages of treatment. Although many case management tasks have a purpose clearly linked to a specific treatment phase (e.g., a good intake report needs to be produced at the start of treatment), two particular tasks with respect to client data are relevant throughout the entire treatment process: keeping good records and maintaining confidentiality (see Figure 8.1).

Keeping good records Professional practice guidelines stipulate that treatment providers must maintain adequate records of all contacts with clients or other persons involved in the treatment (e.g. family members, physicians), indicating date, time, and place of contact, persons present, and the nature of service provided or action taken. Good clinical records provide a clear picture of the patient and a clear account of what the therapist did, when and why. Documentation of these clinical activities serves several purposes (Luepker, 2003): . Records can facilitate communication between therapists and patients. Jointly reviewing reports, test results, data on goal attainment, attendance patterns, etc., can help patients to gain insight into and become active partners in their change efforts, while building trust in the process and the therapeutic relationship.


Case management

Figure 8.1.

Conceptualization, documentation and management of client data

. Records document that a sound diagnosis, case formulation and treatment plan

have been generated. This forms the basis for a purposive course of action and is essential for monitoring and detecting change, or modifying diagnostic impression and treatment strategies. . Records satisfy the accountability mandate. Science-informed practice brings the attitude of a scientist into the clinical consulting room. This includes a commitment to showing proof of what was done when and how to whom, resulting in what outcomes. Contractual obligations with third-party payers often require this information for reimbursement of services. Inadequate records may be interpreted by auditors as health-care fraud, making practitioners vulnerable to criminal prosecution, civil penalties, or suspension of third-party payments (Foxhall, 2000). From an auditor’s point of view, if a service was not documented, it did not happen; if it was billed, it constitutes fraud. . Records assist with continuity of care. Good records of previous interventions can help facilitate treatment planning in the event a patient seeks help again, or needs to be transferred to a different therapist.


Keeping good records

. Records protect therapists and clinical supervisors against spurious allegations

of harmful practices. As in cases of alleged health care fraud, the lack of contemporaneous, detailed documentation makes it difficult for practitioners to prove that they acted in accordance with best-practice standards. Keeping good records allows a therapist to document that decisions and actions were made in good faith and conformed to accepted professional practices. Because of the multiple, simultaneous, challenging tasks that novice therapists must gain mastery over when learning the exciting business of doing therapy, they may be tempted to view the seemingly mundane tasks associated with documentation as an additional burden of secondary importance. It should be clear from the above list of purposes of documentation that conscientious record keeping is an integral part of good case management, and that patient care will suffer without it. Trainees must be mindful not to neglect this important task, but they must also guard against the common tendency among beginning therapists to be overly detailed and comprehensive in documenting their every impression and each piece of information concerning their patients. We will review specific documentation tasks in more detail below, but will first present a few characteristics common to all good clinical records that help to keep records concise, relevant and accurate. . Good records are relevant. They include only information germane to the presenting problem, treatment strategies and outcomes. We will return to this point later when describing strategies for keeping records (and presentations of client information) concise and relevant. . Good records are accurate. They identify the sources of information. For example, if the patient says that her father ‘‘was an alcoholic’’, it would be inaccurate to indicate in the record that ‘‘the patient’s father was an alcoholic’’, because the therapist has no objective information to confirm this as a fact. In this case, the record would be accurate if the therapist indicated that ‘‘the patient stated that her father was an alcoholic’’. Similarly, if the therapist makes an interpretation based on information provided by the patient, this should be made explicit in the record (e.g., ‘‘The patient clenched her fist and raised her voice, almost shouting; she appeared very angry with her husband’s decision’’). In addition to identifying unambiguously the sources of information, accuracy in records is achieved by checking and double-checking for errors. This is particularly important when recording test results and interpretations. . Good records are contemporaneous. They are generated in a timely fashion, preferably immediately after a session or any action taken in relation to case management.


Case management

. Good records are continuous. They are recorded in a chronological order,

each record is signed, and progress notes should be written in a continuous stream. This reduces the possibility of tampering and instils confidence in others that the records are complete. . Good records are consistent. They reflect the course charted in the formulation and treatment plan. If, for example, the aim is to reduce a patient’s fear of flying, a progress note stating that ‘‘the session focused on an exploration of the patient’s rivalry with her stepsister’’ would not be logical in the context of a treatment programme for reducing phobic anxiety, unless reducing distress associated with sibling discord was part of the agreed treatment plan. . Good records are legible. Unless records are legible, they cannot serve the purposes outlined above. Illegible records have the same liabilities as no records at all. Typically entries are written in black ink to ensure that, when copied, any record continues to remain legible. . Good records are sensitive. They avoid jargon, use simple language, and respect the uniqueness and complexity of each patient. A good rule of thumb for the beginning therapist is: if you would feel uncomfortable if the client were to read your report or notes in your presence, you should consider alternative ways of expressing the relevant passages.

Maintaining confidentiality The second task that pertains to all aspects of case management (including record keeping) is the obligation to protect the privacy of the patient. Maintaining confidentiality not only requires attention throughout all phases of treatment, but remains a case management responsibility well after a patient’s active file has been closed. The purpose of confidentiality between a patient and therapist is to create a safe therapeutic environment and to safeguard the patient from harm due to the unintentional disclosure of sensitive patient data. The establishment of trust based on a mutual understanding about confidentiality and its limitations is the foundation of an effective therapeutic relationship. To achieve the best health outcomes for patients, it is often necessary to share information between professional staff as part of multidisciplinary case management, as well as between patients’ families and other carers. Maintaining confidentiality, then, involves maintaining a balance between the need to respect the patients’ privacy and the need to consult with nominated people to optimize patient care, within the guiding parameters set by professional ethics codes and legal obligations. The parameters of confidentiality and its exceptions should be discussed with patients at the start of the first session. Likewise,


Maintaining confidentiality

if communication with families and other carers or professionals is desirable during treatment, an agreement about the purpose, nature and extent of sharing information with others should be reached with the patient. This may require ongoing discussion and negotiation, and may entail the setting of very specific constraints, defining periods of time during which disclosure is permitted, and delineating precisely what may or may not be divulged to whom under what circumstances. Talking about confidentiality with patients

Therapists have the responsibility of explaining confidentiality and its exceptions to patients when commencing a therapeutic relationship. A beginning therapist might worry that having such technical discussions at the outset of the initial interview could be perceived by patients as uncaring and rigid, and hence interfere with rapport building. However, trust in the therapist, and the profession as a whole, will be undermined if total confidentiality is promised or implied without making patients aware of the limitations of confidentiality. Most patients will welcome the therapist’s concern that they understand what is involved in the treatment process, and they are likely to experience this open and frank communication as reassuring. The brief focus at the start of the session on more innocuous procedures can even help to ease trepidations patients may hold about the treatment process, before they talk about what is troubling them and what they are seeking help for. Therapists in training will by definition consult extensively with supervisors and fellow-trainees about their cases. Because supervision is typically aided by the routine review of video-taped sessions, and because the presence of a camera and microphone in the consulting room can be initially intimidating to patients, this special arrangement in training clinics should be explicitly addressed when trainees discuss confidentiality with their patients. The following example shows how confidentiality information can be communicated to a patient. This is not intended as a proscription of how it must be said verbatim, but is meant to illustrate the level of detail and clarity needed to convey in a matter-of-fact yet warm manner what the patient needs to know: ‘‘I like to take a few minutes to explain some of the clinic procedures to you and give you an opportunity to ask any questions you have about our services here’’. ‘‘First, you should know that in general everything we talk about in here is confidential. Of course, creating a safe place for talking about things that are often difficult to talk about and can make one feel very vulnerable is very important in our work together’’. ‘‘As you know, this is a training clinic, and so information about a client is regularly discussed between therapists and supervisors. That is also why many sessions are videotaped. You should


Case management know that these videotapes are not permanently stored. They are only a tool to aid in ongoing supervision and ensure quality in care, and they are typically erased shortly thereafter or taped over with subsequent sessions’’. ‘‘Do you have any questions about the videotaping?’’ [pause for patient to respond] ‘‘There are three circumstances that I need you to tell about, where I might be required by professional standards and the law to disclose information about our sessions to parties outside our clinic:

1. The first one is that, if you were to tell me that you intend to harm yourself or others, I would be required to take some appropriate action to prevent you from doing that and to help and assist you further in that situation.

2. The second circumstance relates to information about abuse or severe neglect of children or the elderly. In that case, I would have to notify appropriate authorities to provide assistance with that situation.

3. The third circumstance where I might have to release information is when I or the clinic gets a subpoena for client records from a judge or court’’. ‘‘Do you have any questions regarding any of these issues relating to confidentiality?’’

The above discussion would typically take less than five minutes. This can be followed with a brief transition statement, outlining the goals and structure of this session, before turning it over to the patient with a phrase such as: ‘‘Ok then, what brings you here?’’

Negotiating confidentiality when working with minors

When working with children and adolescents, therapists need to balance the patient’s need for confidentiality with the parent’s or guardian’s need for information. Therapists must be familiar with applicable laws and statutes governing the withholding of information from parents. Beyond the need to conform to any legal obligations, therapists should consider what level of information sharing with parents, guardians and teachers is most helpful to achieve the best care and outcomes for their child and adolescent patients. Based in part on recommendations summarized by Luepker (2003), the following guidelines can help to determine whether or not to disclose information to parents or guardians: 1. Weigh the pros and cons of telling or not telling other parties. This includes determining if the recipient of the information would be in a position to protect the patient’s privacy and to help with the treatment. 2. Discuss with the parents or guardians the importance of respecting the child’s need for privacy for the success of treatment.


Maintaining confidentiality

3. Explain to parents or guardians the importance of the therapist being able to make professional decisions, in accordance with professional ethics and applicable laws, about what is necessary for others to know. 4. Reassure parents or guardians that they will be informed of any risk which they can help to manage. 5. Limit discussions with teachers and principals to (a) information necessary for the child’s safety, (b) general information about prognosis, such as when they might expect to see change in the child’s behaviour, (c) assurances that the school’s concerns are being addressed in treatment, and (d) things school personnel can do to assist the child’s treatment. 6. Discuss with the child or adolescent the nature and extent of arrangements planned for the exchange of information with others. Luepker (2003) further suggests having parents and guardians sign a confidentiality statement that acknowledges their agreement with the principles listed above in points two to four. Controlling the scope of disclosure

When it is to the benefit of the patient to share confidential information with third parties, the type and extent of disclosure should be carefully controlled. The guiding principle is to restrict the information to be disclosed to the least amount necessary to serve a narrowly defined purpose, for a specified occasion or timeframe, involving a designated target person or persons. Different consent forms should be used that correspond to different types and levels of disclosure. For example, one type of form pertains only to requesting information from others. This deliberately restricts the information flow to one direction only (i.e. from others to the therapist), and does not release any current patient details to the other party (e.g., results from a medication evaluation by a general practitioner). Alternatively, another version provides consent only for releasing information to others (e.g., to the patient’s lawyer in a custody case), but does not permit the other party (e.g., the lawyer) to divulge information to the therapist. Finally, the least restrictive type of consent form allows for the exchanging of information with others. That is, information may flow in both directions. Within each of those general categories of consent forms for disclosure of patient information, each one should be uniquely tailored to a specific purpose, clearly identify which person(s) are to provide or receive information, state the date or event when authorization expires, and document the patient’s right to revoke consent at any time (Luepker, 2003). As a general rule, when disclosing information to third parties, it is best to err on the side of caution and send too little rather than too much information.


Case management

Recipients can always request additional information if necessary. Importantly, unless there are special circumstances defined by law or professional codes as discussed earlier in the chapter, therapists must seek consent of their patients before disclosing any patient information. Thus, when receiving phone calls or letters from third parties offering or requesting information about a patient, beginning therapists must be on guard to not even acknowledge that they know the patient, or that the patient is receiving services. For example, the simple confirmation of a patient being seen at a mental health clinic could have harmful consequences for the patient, if the caller had sinister motives (e.g., a nosy employer or an ex-spouse involved in a custody battle). Therapists can respond to such requests for information that are not covered by prior signed consent agreements by saying: ‘‘All information held at this clinic is confidential. I cannot tell you whether or not the person you are referring to is a patient here. If you want information regarding that person, you need to contact that person directly’’.

Securing patient information

Therapists must ensure that all their patient records are stored securely and locked. Nowadays, information storage and transmission often occur in electronic format, which presents additional security risks that therapists must take care to minimize. Therapists have the responsibility of ensuring that no such materials are exposed in any way to the eyes of the innocent or interested. The following guidelines can help trainee therapists avoid the risks posed by some of the common threats to confidentiality: . Return records (including computer disks and video or audio tapes) to locked filing cabinets immediately after use. . Do not leave any materials on which identifying patient information is visible on counters, desks, floors or in unlocked furniture. . Do not remove any files or patient records from the clinic or authorized premises (see also case example below). This applies to the files themselves as well as to electronic copies. . Ensure that computers or workstations have appropriate security and that the security is operational (e.g., activate a password protected screensaver when leaving your desk). If the computer is networked, ensure that your files are not in a shared directory. . Patient materials should not be duplicated for therapists’ private records. . Make it a routine practice to write in bold letters ‘‘STRICTLY CONFIDENTIAL’’ at the top of all reports, faxes, computer disk labels or other similar communications.


Maintaining confidentiality

. When writing or editing drafts of reports electronically, it is good practice to

only use initials of the patient’s name and disguise other identifying information, until you are ready to print the final version. . When printing patient reports, test results, etc., collect printed materials immediately (e.g., do not stop on the way to the printer to chat with a colleague in the hall; an emergency call or other event can easily divert attention and result in the report being forgotten and left unattended in the printer tray). . In the event of printer problems, always first delete your current print job before attempting to print again (e.g., having pushed the print button repeatedly in the belief it did not work the first time, can result in additional copies being printed and left unattended without the therapist being even aware of it). . When faxing patient records, it is good practice to first call the recipient and ensure that authorized personnel is on standby to collect the transmitted materials. Conversely, when expecting a fax, ensure that incoming faxes are monitored and processed by authorized personnel only. . Erase audio and video tapes of sessions immediately after their intended purpose (e.g., use in supervision) or in accordance with established agency policy. . Do not discuss with others identifying patient information in hallways, reception areas, elevators or similar environs that are open to the public or non-authorized personnel. The following case example illustrates how the failure to follow these basic guidelines in securing confidentiality of patient information can lead to serious potential risk for the clients involved, as well as to serious repercussions for the trainee therapist responsible for the breach in security. Case example. A student had taken various confidential case materials out of the treatment centre with the intention of completing several assessment reports at home. While the case materials were still in the student’s car, the vehicle was stolen along with all the confidential case materials and some expensive testing kits. One of the serious implications for the affected clients was that the breach in security and the resultant failure to protect the clients’ confidential details made them vulnerable to the risk of identity theft. The repercussions for the student responsible for this security breach were appropriately severe. The student failed the practicum course, had to repeat an ethics course, had to purchase two test kits that had been stolen, had to recreate each of the clients’ files, and had to inform the clients about the theft and the potential threat to their confidential details. Although most clients took the information well, one client expressed concern over becoming a victim of identity theft. In response, the training clinic offered the client a one-year membership to an identity theft company.


Case management

As this example illustrates, a breach of confidentiality resulted as a direct consequence of a student failing to adhere to established case management policies and procedures. It underscores the point made at the beginning of this chapter; there is no good treatment without good case management. Tasks associated with the intake and treatment planning phase In the following sections, we will review the key case management and documentation tasks associated with intake and treatment planning (see Figure 8.2). Good management of the intake and treatment planning phase is essential for getting the treatment off to a good start. It facilitates early rapport building, generates momentum for change, and sets the tone for a goal-oriented working relationship with the client. Getting treatment under way

The first case management task is to seek informed consent from the client prior to carrying out any assessment or intervention. Many clients sign informed

Figure 8.2.

Tasks associated with the intake and treatment planning phase


Tasks associated with the intake and treatment planning phase

consent forms as part of their application for services, others may wait until their first appointment to clarify any questions before signing. In either case, the parameters of the treatment process should be discussed before commencing therapeutic work. These include the limits to confidentiality (discussed earlier in this chapter), payment procedures, scheduling of sessions, arrangements for consultation with third parties if applicable (e.g., monitoring medication by a psychiatrist, referrals for specialist testing, or periodic joint sessions with a spouse). When a client is accepted following a referral, the nature of the involvement (if any) of the referral source needs to be clarified. Regardless of the extent of their continued involvement, referrers should be advised whether or not a referral has been accepted. In addition to obtaining informed consent and clarifying referral issues, it is the therapist’s responsibility to consider any ethical issues before providing services. For each client, therapists have a professional duty to make a judgement if their abilities match the needs of the presenting case, or if other circumstances (e.g., prior acquaintance or relations with the client outside the therapeutic context) could jeopardize optimal client care. In those instances, clients should be referred to another professional. Once a decision is reached to take on a client, a file needs to be opened that contains the signed consent form and any relevant referral information. Presenting and documenting case information

An important aspect of good case management is the therapist’s ability to communicate to others verbally and in writing who the client is, what the presenting problem is, what the factors are that cause and maintain the presenting problem, and how these factors can be influenced by the proposed treatment plan. Presentation of summary case information during the intake and treatment planning phase occurs in two main formats: brief verbal presentations at clinical staff meetings or rounds and succinct written intake reports. The operative words here are brief and succinct! Unfortunately, the aim of achieving brevity and succinctness in presenting case information tends to conflict with the novice’s understandable anxiety over evaluation and their fragile confidence in knowing what details are germane to the case and should or should not be included when presenting a case. As a consequence, novices often test the patience of their colleagues and supervisors by indulging in meandering discourse about their patients’ life journeys, only to end up rushing through what is the most important part of communicating case information  offering an integrative case formulation along with specific, measurable treatment goals derived from it. Unduly long presentations and reports also result from a tendency among novices to use templates of the structure and content of case


Case management

reports inappropriately as a mandatory proscription to cover every point of the template, rather than using the template as a guide to be selective about which aspects of a case are the most germane for enabling others to understand the basis for the case formulation and treatment plan. What, then, is the cure from the novice’s affliction to produce case presentations and reports that typically are too long to be useful in the fast-paced reality of modern clinical practice? The first antidote to overly long case presentations and reports is to remember that clinical psychology services are delivered in a competitive health-care market where time is a precious commodity. Put simply, there is no time for long presentations. Long reports do not get read and unread reports are not in the best interest of your client. The second antidote is to approach preparation of case presentations and reports not in the order in which they are eventually delivered (client details, presenting problem, background, etc.), but by first writing out the case formulation and treatment plan. For example, presenting a formulation and treatment plan should take about 2 minutes. That means there are about 3 minutes left out of a finite total presentation time of circa 5 minutes. Thus, the number of background details that can be presented must be restricted to those that are the most relevant and that best illustrate the rationale for the formulation and treatment plan, while still fitting within the remaining 3-minute time limit (see Figure 8.3). The primary purpose of a case presentation is quality assurance. That is, an integrative case formulation and the treatment plan that follows from it are

Figure 8.3.

Schematic illustration of the relative importance of case presentation components


Tasks associated with the intake and treatment planning phase

presented to colleagues for the purpose of feedback and consultation. Therefore, precious presentation time must be used wisely, with the components covering case formulation, treatment plan, and consultation with colleagues receiving the greatest weight (see Figure 8.3). The primary purpose of case reports is accountability. Similarly to case presentations, the emphasis in case reports should be on the case formulation and treatment plan, with details from background information, current interpersonal and social functioning, and scores on objective assessment measures serving as evidence to support and selectively illustrate the rationale behind the case formulation and treatment plan. Because the complete test results are available in the patient’s file for future reference, and because background details, if they were relevant enough to be recorded in the progress notes, can be retrieved at any time if necessary, it is sufficient for summary reports to only include illustrative key details supporting the formulation and treatment plan. This will ensure that case reports are succinct, focused on the presenting problem, and practical in day-to-day case management (see Chapter 3 for a comprehensive list of intake information from which key client data would be selected for inclusion in a case report). Notwithstanding the importance of succinctness in presenting and documenting case information, case reports do require greater detail when the assessment indicated that the treatment must also be accompanied by a risk management plan. Assessing and managing risk

The burden of determining when clients are at risk to harm themselves or others weighs heavily on any therapist, especially on the inexperienced trainee. With respect to self-harming behaviours, the disconcerting fact is that they cannot be reliably predicted at the level of the individual (Rudd et al., 1999). Suicidal states are variable and usually time limited in nature, and they are modifiable in response to treatment. Therefore, the continual monitoring, assessment and documentation of current risk level is an essential part of good case management. Science can serve as an ally in the effective management of risk (Seligman, 1996a), because the burden of uncertainty can be allayed somewhat with the help of empirically derived practice guidelines on how to assess and manage suicidal clients. An empirically grounded decision framework for determining the level of risk associated with suicidal symptoms, and what actions to take depending on the severity of risk, has been described by Joiner and his colleagues (Joiner et al., 1999). According to this decision framework, the mere presence of some suicidal ideation is not very useful in determining risk status, because some suicidal thoughts are encountered routinely among treatment-seeking individuals and are


Case management

not uncommon even in the general population. The most crucial variables determining suicide risk are history of prior attempts combined with the nature of current suicidal symptoms and the number of other known risk factors. Accordingly, the first step in the assessment of suicide risk severity is to determine if the client can be categorized as a multiple attempter or non-multiple attempter, because the baseline risk for multiple attempters is always elevated compared to single attempters and mere ideators. Therefore, risk is assessed differently for multiple and non-multiple attempters (see Figure 8.4). The presence of at least one risk factor translates into at least a moderate risk level for multiple attempters, but not necessarily for non-multiple attempters, unless it involves resolved plans and preparation to commit suicide. Thus, the second step in assessing risk severity is to determine if the client has a plan, how specific that plan is, if the means and opportunity to execute the plan are available, and if the client has made any preparations for the attempt. One should also consider here the duration and intensity (rather than frequency) of suicidal desire and ideation. The third step in suicide risk assessment is to identify if there are additional risk factors that can raise the level of risk beyond that associated with the domains of resolved plans and preparation or suicidal desire and ideation alone. These risk factors include (a) recent stressful life events (e.g., divorce, legal troubles), (b) diagnostic comorbidity (especially mood and anxiety disorders, alcohol use and hopelessness), (c) chaotic or abusive family history, (d) impulsive behavioural style, and (e) limited social connectedness. Once the level of risk severity has been classified as either low to mild, moderate, or severe to extreme, different risk management strategies are called for depending on the level of risk. Table 8.1. summarizes the various risk management activities associated with each level of severity. It also provides example statements of how to discuss with clients the risk management activities at each level of intervention. It is recommended that patients at moderate risk be given a crisis response plan on a card that they can carry with them at all times (Joiner et al., 1999; Oordt et al., 2005). The card has a step-by-step list of what to do when thoughts about suicide occur, including phone numbers of alternative support services (e.g., ‘‘If the thoughts continue, and I find myself preparing to do something, I call the clinic at: _____’’; or ‘‘If I cannot reach anyone at the clinic, I call: _____’’). The importance of routinely documenting all decisions and interventions for maintaining the safety of clients until the suicidal risk has been resolved cannot be overstated (Rudd et al., 1999). In terms of the characteristics of good records, more detail than usual is appropriate, because details are highly relevant in the context of risk management. In this instance, failure to be thorough can compromise patient safety, as well as the therapist’s ability to prove


Tasks associated with the intake and treatment planning phase

Figure 8.4.

A decision framework for the assessment of suicide risk severity (based on Joiner et al., 1999)

that the level of care conformed to professional standards of empirically grounded practice. In addition to assessing and managing any risks to a patient’s own safety, it may also become necessary to respond to situations where the patient’s


Case management

Table 8.1. Summary of what to do in response to different suicide risk categories.

Risk severity

Risk management activities

Example statements


Continued risk assessment

‘‘In the event that you start feeling that you want to harm yourself, here’s what I want you to do: First, use the skills for self-control we’ll discuss, such as challenging your negative thoughts and seeking social support. If suicidal feelings remain, contact me or the clinic. If you are unable to reach anyone, or, if you feel you need assistance straight away, call or go to the emergency room  here is the number’’.

Document in progress notes

‘‘Have you had any thoughts of harming yourself since I last saw you?’’ MODERATE

Increase frequency of sessions Involve supportive others Stay in touch via phone contacts Consider medication Provide detailed emergency plan Monitor changes in risk level

‘‘It is important that we put some strategies in place that keep you safe and help you gain control over your suicidal feelings.’’ ‘‘One of the things that will help you is. . .’’ ‘‘Until you feel things are under control again, I recommend that for the next [time period] we schedule more frequent visits’’.

Reevaluate treatment goals Seek consultation Document changing risk levels Document clinical decisions

‘‘I want you to carry this crisis response plan card with you at all times. It lists the steps you need to take when thinking about suicide. Do you agree to follow those steps when thinking about suicide?’’

Document actions taken Document risk resolution SEVERE to EXTREME

Accompany and monitor patient

‘‘At the moment you are not safe on your own’’.

Evaluate for hospitalization Involve emergency services

‘‘Is there someone in your family that we can contact right now?’’

Involve family members

‘‘I am calling emergency services so they can assist us getting you to the hospital for evaluation and crisis care’’.

Seek consultation Document risk status Document clinical decisions Document actions taken Document risk resolution

‘‘I am going to ask my colleague/supervisor [add name] to come and join us while we are waiting for your family/emergency staff to get here’’. (continued )


Tasks associated with the intake and treatment planning phase

Table 8.1. (continued )

Risk severity

Risk management activities

Example statements Note: If highest risk category becomes apparent during a phone contact, ask the following questions right away: ‘‘Where are you?’’ [do your best to determine the exact location] ‘‘What is the phone number there, in case we get disconnected?’’ ‘‘Are you alone or is someone with you?’’ ‘‘Have you eaten or did you drink anything that is dangerous to you health?’’ ‘‘Have you harmed or injured yourself?’’

behaviour, or expressed intent to act, constitutes an imminent risk to others including the therapist. When such a crisis situation arises, the therapist must initiate emergency procedures. Although it is likely that a supervisor will be at hand to assist with or handle a crisis situation, every trainee has the responsibility to not only be aware of the emergency procedures pertaining to their training clinic or clinical placement sites, but to know them by heart. Once a crisis unfolds, it is too late to consult the procedures manual for guidance. Emergency procedures are usually tailored to specific demands associated with the locale, type of client population, availability of on-site staff, and proximity of support services such as police and psychiatric emergency response teams. Because these demands can vary considerably across sites, the onus is on the trainee to become thoroughly familiar with the emergency procedures specific to each training site. In general, all emergency procedures share the following core principles: . Foremost, be aware of your own safety and that of others in close proximity. . If necessary, get yourself and others away from the danger. . Notify everyone in the clinic of the emergency situation (e.g., activate panic button in the consulting room; alert the reception staff). . Notify any available supervisors. . Request intervention by security staff, police or psychiatric emergency response units. When it becomes necessary to involve specially trained emergency response personnel, the therapist needs to be prepared to tell them everything they want to


Case management

know about the client and to listen to their advice on how the situation is to be handled. They are the experts, and once they are on the scene, they are in charge and the responsibility for the patient’s well-being rests with them. Finally, there are situations where the risk is not imminent, but where a client’s behaviour nonetheless poses a potentially serious risk to others. For example, an HIV-positive patient might tell the therapist that he or she is engaging in unprotected sex with their partner(s) who are unaware of the patient’s disease status. In many jurisdictions, therapists have a legal obligation to report infectious diseases to health authorities. In some jurisdictions, there are also provisions for health-care providers to protect and notify identifiable others. In these situations it is good practice for therapists to seek legal advice on reporting infectious and potentially harmful conditions without the patient’s consent (Luepker, 2003). As always, all activities associated with the risk management of such cases must be carefully documented in the client’s file.

Tasks associated with the treatment implementation phase Once an intake report has been filed, baseline assessment data have been collected for each treatment goal, and treatment has commenced, the focus of case management is to ensure that the therapeutic process unfolds in a manner consistent with the treatment plan. Thus, the key management tasks associated with the treatment implementation phase are (a) the routine review of progress toward goal attainment, which may necessitate adjustments to the treatment plan or diagnostic impression, and (b) the initiation of preparatory steps that will strengthen the client’s capacity for independent coping upon termination of treatment (see Figure 8.5). If applicable, risk management activities need to be executed as planned and carefully documented, noting any change in risk status and any modifications to the risk management plan, and the reasons for those modifications. In the fiscal domain of case management, therapists must monitor the payment of services and keep accurate billing records which document the date, length and type of services, the cost of the services, and in what form payment was received (e.g., cash, cheque or credit card). Documenting progress toward goal attainment

All events associated with the treatment of a client should be recorded in the progress notes. These provide records of every contact with the client (by phone, in person or by mail), or concerning the client (e.g., a phone call to arrange aftercare services), as well as an up-to-date summary of therapy sessions. Table 8.2 provides an outline and examples of how to write a typical progress note.


Tasks associated with the treatment implementation phase

Figure 8.5.

Tasks associated with the treatment implementation phase

Initiating termination planning

The ultimate goal of treatment is to help clients to regain agency over their lives and emotional well-being in the shortest period possible. Thus, termination of treatment becomes an automatic goal as soon as the client walks through the door for the first appointment. In order for the client and therapist to know when treatment can be brought to a close, it is important for the therapist to consider this question jointly with the client throughout the treatment process as part of ongoing case management. Of course, thinking about the time after treatment and being on their own again without the regular support of the therapist may be furthest on the mind of clients who have just turned for help because they felt helpless on their own. Similarly, beginning therapists understandably get preoccupied with the immediate demands of current treatment, rather than preparing simultaneously for the more distal time when they are not needed anymore by the client. Thus, the fear of the client to be abandoned by the therapist before the client feels ready, and the inclination of the therapist to aim for the best possible treatment outcome before letting go of the client, can conspire to overshoot the target and


Case management

Table 8.2 How to write progress notes.



Examples from different clients



‘‘Came on time, neatly dressed, sat stiff and tense the whole interview, occasionally fidgeting with things on the table; seemed anxious and angry’’.


sentence describing the client’s appearance moods and feelings behavior

‘‘Came ten minutes late, un-ironed clothes, sat motionless staring at the floor, seemed deeply dejected’’.

A sentence or two on what the client told the therapist about  changes in symptoms and behaviour  changes in life situation  new insights  thoughts on previous session or treatment goals

‘‘He said he was working more, but still unable to sleep and the quarrels with his wife were getting worse’’.


A sentence stating what the primary goal(s) was (were) for the session

‘‘The primary goal of the session was to examine X’s catastrophic thinking in response to her recent worries about her upcoming promotion to head one of the regional company offices’’.


A sentence or two on the overall content of the session, and a statement to what extent the session goal(s) was (were) met, or to what extent overall treatment goals were successfully addressed

‘‘He began by complaining about his wife, but toward the end of the session was talking more about how he may be contributing to what went on. This insight represents significant progress toward him taking more responsibility for his part in the ongoing distress and frustration he experiences in interpersonal interactions. The conflict with his wife served as an example for continuing with the assertiveness module and practicing alternative approaches to communicating with his wife’’.


A sentence indicating goals for the next session or any changes or innovations in the treatment plan

‘‘In the next session, we will again emphasize behavioural training in social skills via role plays, now that trying to gain insight into the reasons for her shyness seems to have led to little change in the level of social interactions for the client’’.

‘‘She said that the children were getting along better at daycare and she wasn’t so irritable at work anymore and that she and her husband seemed to be talking better. Now that communication within the family has improved, she wants to focus more on her goal to take up again some non-family related activities’’.

(continued )


Tasks associated with the treatment implementation phase

Table 8.2 (continued )



Examples from different clients


If applicable, important statements by the therapist or client should be recorded verbatim

‘‘I said that at this point it would be best for her to participate in the group programme offered at GetWell Hospital’’. ‘‘He described his boss as a ‘liar and womanizer’, and he believed that he had no chance of promotion despite his boss promising he ‘was next on the list’ ’’.

unnecessarily prolong treatment. That is, the failure to initiate termination planning early in treatment could lead to a bumpy ending of the therapeutic relationship, rather than a smooth transition toward closure and a return to life without therapy. Further, for individuals who require in-patient treatment, it is good practice to discuss possible discharge dates early in the hospitalization and subsequent plans for follow-up care so that patients have a clear concept of the treatment plan. Routine termination planning during the treatment implementation phase helps the therapist to determine when treatment is good enough (see also Chapter 13 on the concept of good enough treatment). It also ensures that any distress associated with feelings of loss or abandonment that a client may experience as a result of terminating the therapeutic relationship can be dealt with in a gradual and supportive rather than abrupt fashion. There is a simple way of incorporating termination planning during treatment that is nonthreatening and informative for both client and therapist. Early in treatment, the therapist can initiate termination planning by telling the client that ‘‘therapy has a beginning, middle, and end’’, followed by the question, ‘‘where do you see yourself at this moment in treatment?’’ The simple opening statement raises the awareness of the client that treatment is time-limited and progresses toward a logical endpoint. At the same time, the use of an open-ended followup question reassures the client that the decision about ending treatment is reached collaboratively involving the joint input of client and therapist. The answers clients give to that question are often eye-opening for beginning therapists and serve as a reality check. Novice therapists are less experienced in picking up cues from clients that treatment gains have solidified, or have already generalized to domains in the clients’ life that were not particularly targeted by the treatment. Consequently, novices tend to underestimate their


Case management

Figure 8.6.

Tasks associated with the evaluation and termination phase

clients’ readiness for termination. The use of routine termination planning can help to correct for this bias and ensure that the focus of valuable session time at the latter stages of treatment matches the clients’ increasing readiness for moving on. Tasks associated with the evaluation and termination phase Ideally, goal attainment signals the end of treatment. Therefore, the key case management tasks during the evaluation and termination phase are to collect final outcome data, examine the change from baseline values, and evaluate the clinical significance of the change in relation to the goals specified in the treatment plan (see Figure 8.6). If there is only partial change, or no change at all, or a worsening of symptoms in some areas targeted by the treatment, then the therapist should consider follow-up services. If it is clear that the client would not benefit from simply extending services, a referral to alternative treatment providers should be considered. Analogous to brief case presentations during


Tasks associated with the evaluation and termination phase

the intake phase, where therapists share case information with colleagues for consultation on treatment decisions and planning, therapists often present a brief update or termination summary to their colleagues, who can provide reflective feedback on aspects of the treatment or suggestions for follow-up strategies if applicable. In terminating relationships with clients, therapists must have the best interest of the client in mind and show regard for the client’s ongoing well-being. In the event that therapists must terminate treatment prematurely due to personal reasons (e.g., illness, change of employment, extended leave of absence), they should provide clients with an explanation of the need for such early termination and take all reasonable steps to arrange for alternative care. If a risk management plan was in place during treatment, an important case management responsibility is to re-assess risk status immediately prior to termination. Readiness for termination is contingent upon resolution of the circumstances that had put the client at a heightened level of risk at the start of treatment. Resolution of risk status needs to be carefully documented in the termination report. Should the assessment of risk status indicate any residual level of risk for the client, the therapist must document carefully what preventative steps have been taken to ensure the client’s safety after the end of the therapeutic relationship. A major documentation task at the end of treatment is for the therapist to produce a succinct termination or transfer report. A termination report should contain the following information: . Introductory summary: A brief statement about the presenting problem(s), the number of sessions, and the time period over which services were provided (e.g., Ms P self-referred to the clinic for depression and relationship problems. She was seen for eight sessions between 16 November, 2005 and 29 March, 2006). . Focus of treatment: A brief paragraph on the treatment plan and the strategies used to address goals of the plan. . Progress and goal attainment: A paragraph stating what goals have and have not been achieved with direct reference to objective outcome measures (including a statement on risk resolution if applicable). . Concluding recommendation(s): A brief statement about the reasons for termination and whether termination was mutually agreed upon, any specific arrangements for continuing care, and recommendations for relapse prevention and/or follow-ups if applicable. The final case management task is to close the client file in a timely manner and ensure that it is stored securely in accordance with ethical guidelines and applicable legal obligations.


Case management

The processes of case management may appear difficult, and the prospect of juggling these management responsibilities alongside the many tasks associated with conducting therapeutic interventions may seem daunting. However, this is where availing yourself of competent and experienced supervision can be of real benefit. Clinical supervision will be the topic of the following chapter.



Making the most of supervised practice Supervised practice is paramount to the teaching and learning of psychotherapy (Watkins, 1997). The novice therapist in a university training programme typically receives formal supervisory feedback at least once a week, and often benefits from additional ad hoc and informal guidance by readily available supervisors. After graduating, therapists move on to positions where their contracts stipulate and guarantee them the accumulation of a required minimum number of supervised practice hours for accreditation. Once accredited, however, supervision is often harder to come by. Recent reviews of clinical supervision in various mental health professions (Spence et al., 2001; Strong et al., 2003; Townend et al., 2002) concluded that the realities of high case loads, higher priority of crisis management, poor access to supervisors, and lack of clear policy guidelines are cited as reasons for many practitioners receiving little or infrequent supervision. For example, in a sample of 170 cognitive behavioural therapists in the UK, the mean number of supervision hours received was just over two hours per month for 52 hours of direct face-to-face client contact (Townend et al.). Thus, the intense level of supervision available during the initial training of psychotherapists is a time-limited privilege! Moreover, in a survey of over 4,000 psychotherapists with different professional backgrounds, career levels, theoretical orientations and nationalities, getting formal supervision was rated as the second most positive influence on their career development, after the experience of working directly with clients (Orlinsky et al., 2001). With that in mind, novice supervisees should be highly motivated to be actively engaged in their supervision, and to make the most of this important and valuable aspect of their training. Goals of supervision for science-informed practice Supervision is an interpersonal intervention that is both collaborative and evaluative. It has the simultaneous goals of developing in supervisees the skills



Figure 9.1.

An illustration of how the four primary goals of supervision map onto the treatment process highlighting the sources of client data available for supervisory input

for science-informed practice, monitoring the quality of the treatments delivered, and providing a safeguard that keeps a supervisee who puts clients at risk from entering the profession (Bernard & Goodyear, 2004). In addition, by encouraging self-efficacy in supervisees (Falender & Shafranske, 2004), and by supervisors serving as role models, supervision provides a supportive learning environment for supervisees to develop their own professional identity. Figure 9.1 illustrates how these four primary goals of supervision map onto the processes of the science-informed practice model introduced at the beginning of this manual. The development of skills and competencies focuses on the specific clinical tasks involved in linking client data to case formulation, treatment planning, implementation and outcome evaluation. As such, ‘‘supervision provides the structure and framework for learning how to apply knowledge, theory, and clinical procedures to solve human problems’’ (Falender & Shafranske, 2004, p. 6). The aim of enhancing the professional functioning of the supervisee in these essential clinical tasks goes hand-in-hand with the supervisor’s primary ethical responsibility of monitoring client care. The supervisor must assure that


Goals of supervision for science-informed practice

the quality of the services delivered by the supervisee meets appropriate standards and achieves optimal outcomes for the client. In cases where formative feedback has failed to enhance the supervisee’s competence and readiness to assume the role of an independent practitioner, the supervisor’s summative assessment serves a gatekeeper function to protect the welfare of clients, the integrity of the profession and society at large. In addition to enhancing professional functioning and monitoring quality of client care, supervision serves the function of socializing supervisees into their professional discipline (Bernard & Goodyear, 2004). That is, the personal growth experienced by supervisees during training, as they gain experiences and mastery in clinical practice, occurs in close association with the role models provided by senior members of the supervisee’s own professional discipline. This collaborative process allows supervisees to develop a professional identity, along with a clear sense of the unique contribution they can make within the context of health-care delivery systems that are increasingly multidisciplinary. Good supervision must achieve a delicate balance in meeting the four goals discussed above. This poses quite a challenge, because the relative weight assigned to each goal varies depending on the stakeholder involved. Figure 9.2 shows how the supervisor needs to consider the welfare of three principal stakeholders: the client, the clinician, and society at large. For example, quality assurance is of utmost importance to the client as well as society and supersedes educative and training goals of the clinician. At the same time, beginning therapists are expected to make mistakes and will need to hone their skills.

Figure 9.2.

The relevance of the four primary goals of supervision for three classes of stakeholders



This may result in some delays and detours before treatment strategies, with the benefit of formative supervisory feedback, are successfully implemented. The integration of the dual tasks of providing supervisees with practical experience in learning how to apply their knowledge and skills to the provision of clinical services, and ensuring that client welfare is not compromised in the name of training, requires careful consideration of the sources of data available for supervisory input and oversight (see Figure 9.1). Some client data (e.g., test results, video-taped verbal and non-verbal behaviour) are directly available for inspection by the supervisor, but much data (e.g., supervisee self-report of session content or process) will first pass through the selective and interpretative lens of the supervisee. It is therefore important that supervisees learn to present supervision data in a way that maximizes their utility for skills enhancement, professional growth and quality assurance. Before we discuss what supervisees need to do to achieve this, we will explain how the conceptualization of supervision goals within a science-informed model of practice, as illustrated in Figure 9.1, is consistent with current competency-based approaches to supervision. A competency-based approach to supervision A scientist-practitioner looks for valid theoretical models to guide his or her professional activities. In the case of supervision, there is no shortage of available models, but empirical support for most of them is scarce, and many simply present personal views and anecdotal accounts of various aspects of supervision (Spence et al., 2001). Another significant problem with many current models of supervision is that they lack the specificity to tie the primary supervision goals to particular supervision strategies and processes, which in turn target the key components of clinical practice (Gonsalvez et al., 2002). Traditionally, several models were developed as a direct extension of a particular psychotherapy theory. Proponents of such psychotherapy-based approaches emphasize that supervision practices should reflect the particular theoretical orientation a supervisor holds with respect to treatment. For example, whereas cognitivebehavioural supervision is highly structured, emphasizes exploration, conceptualization, and modification of thoughts and beliefs, and uses didactic teaching and homework assignments to enhance skills (Liese & Beck, 1997), Gestalt supervision is less skills-oriented, avoids didactic instruction, and instead aims to provide supervisees with conditions that will help them to implement the therapeutic attitudes necessary to affect therapeutic change in clients (Patterson, 1997). One would expect supervisory practices to greatly differ for such different schools of thought, but when one examines what supervisors actually do in


A competency-based approach to supervision

supervision sessions (see Watkins, 1997), it is apparent that ‘‘irrespective of professional and theoretical background, supervisors engage in very similar supervisory practices’’ (Spence et al., 2001, p. 138). This should not be surprising, because the aims of supervision, while they map onto the treatment process, are not equivalent to the aims of treatment, nor are treatment knowledge and skills readily transferable to the supervisory context (Falender & Shafranske, 2004). Moreover, contemporary models of psychopathology and treatment are multidimensional and integrative rather than based on a single theoretical model (Barlow & Durand, 2005). Hence, a useful model of supervision is one that embraces explicitly the need to be adaptable in light of current advances in the literature. In fact, a rigid adherence to a single, narrow, theoretical orientation early in training can lead to stagnation and impede the further professional development of supervisees (Neufeldt, 2003). There are also supervision models that are not based on a particular theory of psychotherapy. For example, developmental approaches to supervision assume that supervisees change as their training progresses from novice to advanced status, and that supervisory practices should be matched to the supervisee’s needs at a given level of experience and expertise (e.g., Stoltenberg & McNeill, 1997). These models highlight that a large part of a therapist’s development occurs after formal training has ended (Neufeld, 2003). This broad perspective of novice-to-expert development extends well beyond the scope of the time-limited, formal training period most relevant to the beginning therapist. Further, there is much variation within and across developmental training levels. For example, an advanced trainee may need the type of supervisory input more typical of a novice trainee when faced with a crisis situation, or when transfer of skills to new clients and situations proves very challenging. As with the psychotherapybased approaches, empirical support for developmental models of supervision is limited, although there is some support for the notion that inexperienced trainees benefit most from structured and directive methods (Spence et al., 2001). Finally, process-based approaches to supervision emphasize that supervision is a unique professional praxis that involves specific roles, tasks, and processes within a supervisory relationship with the aim to facilitate the teaching and learning of specific competencies (Bernard & Goodyear, 2004). As illustrated in Figure 9.1, these competencies are evaluated against the measurable outcomes of supervisees’ clinical interventions. The explicit articulation of supervision components that are linked to the primary supervision goals provides the framework for initiating, developing, implementing and evaluating the processes and outcomes of supervision (Falender & Shafranske, 2004). That is, a competency-based approach to clinical supervision is goal-directed and accountable to stakeholders.



Therefore, the development of competencies requires deliberate practice, rather than simple experience (Neufeldt, 1999). This means that supervisees must fully engage in the supervision enterprise and apply to their own learning the selfcritical and reflective attitude that is the hallmark of scientific inquiry, hypothesis testing and outcome evaluation (Shakow, 1976).

The reflective supervisee Reflectivity in clinical practice is the deliberate process by which practitioners frame problems, modify their behaviour to test solutions, evaluate the outcomes of these tests, and then decide how to proceed in their work with clients in light of these insights (Neufeldt, 1999). Supervision aims to instil in supervisees this reflective approach to practice. The process of reflectivity is initiated when the supervisee encounters a situation in which she or he is puzzled or feels stuck and is unsure how to proceed. That is, ‘‘the trainee’s feelings of uncertainty signal a problem ripe for reflectivity’’ (Neufeldt et al., 1996, p. 6). Supervisees must learn to tolerate this ambiguity and use it constructively to guide their clinical thought processes and decision making. They must resist the inclination to cover up with defensive impression management arising from an understandable desire to not appear incompetent. Reflectivity in supervision is only complete if it results in supervisees changing their behaviour in subsequent sessions. We will draw on the integrated model of reflectivity described by Neufeldt and her colleagues (1996) to illustrate with an example what the supervisee’s role, tasks and responsibilities are throughout the sequential and iterative process of engaging in, and learning from, reflective supervision. The trigger event

Consider a novice supervisee who is experiencing considerable frustration in her first couple of sessions with a new client, because the client ‘‘does not provide much detailed information and seems reluctant to respond to follow-up questions when asked to elaborate on points’’. Following the trigger event

A reflective supervisee reacts to the trigger event as follows: She (a) is puzzled or feels stuck and unsure how to proceed, (b) knows that feelings of uncertainty signal a problem ripe for reflectivity, (c) takes responsibility for learning and professional growth, (d) avoids defensive self-protection, tolerates a sense of vulnerability, and is prepared to take a risk, and (e) is proactive and presents trigger event in supervision.


The reflective supervisee

Prior to supervision

A reflective supervisee understands that most of her learning occurs between supervision sessions. Therefore, she engages in several preparatory activities: She (a) uses self-assessment and selects valid information about the trigger event (e.g., relevant video passage of a typical incident of the client not responding to supervisee’s questions), (b) considers own actions, emotions and thoughts during the incident (e.g., How did I feel during the silence? Am I getting anxious to do something during silent moments with the client? What was I thinking? Was I worried about getting through all my questions I had prepared? Did I give the client enough time to answer?), (c) considers the interaction between the client and self during the event (e.g., What am I doing? What is the client doing? Did my follow-up questions interrupt the client’s thoughts? Would the client have answered had I shut up for just a little longer? How would I respond myself to rapid-fire questions from someone?), and (d) formulates a summary statement about the event and any insights or questions gleaned from the self-assessment to take into the next supervision session. During supervision

The reflective supervisee brings a stance to supervision that is characterized by intent to understand what has occurred, and by an openness to accept and try solutions generated with the guidance of the supervisor. Hence, she (a) is open to new ideas, (b) critically examines supervision data such as a pre-selected video clip (e.g., Client appears to be contemplating answer. Client shifts body and begins to open mouth, but then stops and listens to my next question), (c) entertains alternative explanations (e.g., Client is not reluctant to answer. Rather, I am impatient, and the client is polite and/or not assertive enough), and (d) formulates alternative explanations as hypotheses and plans how to test these new ideas with the client in the next session (e.g., I will sit back after asking a question to rein in my impatience and to signal to the client it is her turn. I will tell myself that silence is OK. I will wait for the client to answer. I will attend to and observe outcomes of this deliberate change to my behaviour). During subsequent session with client

The reflective supervisee understands that an event becomes reflective only if the supervisee changes behaviour as a result of the reflective process. Consequently, she (a) puts into action her plan to experiment and test the new ideas developed during supervision, and (b) uses reflection-in-action, that is, she attends to and evaluates what is happening while it is happening during therapistclient interactions (e.g., Client answers after a delay. Silence does not feel so



uncomfortable after all. Let me try this again with the next question. Yes, it works again. Now look what happens, the client becomes talkative. I relax. I am getting somewhere with this client.) Following subsequent session with client

The reflective supervisee contemplates the consequences of her experiment. She (a) evaluates outcomes of having used new behaviours and strategies (e.g., What worked and what did not work? Does the client provide more detailed information and respond to follow-up questions when asked to elaborate on points?), (b) selects valid information to document conclusions drawn from the above evaluation (e.g., relevant video passage(s) of attempts to use new strategy), and (c) goes through the routine steps of considering own actions, internal experiences and dynamics of the interactions with the client, and then prepares a summary statement to take to the next supervision session. During subsequent supervision session

The reflective supervisee takes responsibility for following up with her supervisor on any treatment decisions and plans suggested to her during the previous supervision session. She (a) updates supervisor on outcomes of previously recommended changes to her in-session behaviour, (b) critically examines supervision data (e.g. pre-selected video clip of events that were targeted with newly adopted strategies), (c) considers the need for further refinement or alternative strategies, and (d) plans to consolidate new skills, transfer new skills to other situations, or test alternative ideas.

Setting an agenda As we have highlighted in the first part of this chapter, a science-informed, competency-based approach to supervision requires that the supervisee is an active participant in supervision. There are a number of simple strategies that further assist supervisees in harnessing the anxiety they inevitably experience in their initial work with clients, so that they can make the most of the guidance provided by their supervisors. Evidence suggests that inexperienced supervisees benefit from directive and structured supervision methods (Spence et al., 2001). One such method is setting an agenda for the supervisions sessions. Coming to supervision without a plan of what issues demand the most attention is the least productive way to utilize precious supervision time (Bernard & Goodyear, 2004). In contrast, developing a tentative agenda for their supervision sessions is


Learning from (audio-) videotapes

empowering to supervisees (Pearson, 2004). At the beginning of each supervision session, supervisees should be prepared to do the following: 1. State what client contact has or has not occurred since last supervision. 2. Identify which issues with what clients need to be attended to. 3. Prioritize the importance of these issues. This includes estimating and requesting specific periods of time for each issue keeping in mind the total available time. 4. State how this time is best to be used (e.g., I like us to review and discuss about 6 minutes of videotape with Client A, and for Client B, I like to know whether I need to shift greater focus on the third goal of the treatment plan, and how I should go about doing that; this probably shouldn’t take more than 10 minutes, since we already touched upon this last time). 5. Clearly identify your most immediate needs. As you help setting the tentative agenda, let your supervisor know what you definitely need to take away from this particular supervision session. One might call this stating your conditions of satisfaction. That is, what is the absolute minimum you need to achieve during this supervision session, so that you can be satisfied that you have a plan and a reasonable degree of confidence for going into your next client sessions? 6. If supervision occurs in a group-format, agenda setting may involve some negotiation and trade-offs between supervisees within and across supervision sessions in light of perceived urgency and complexity of all issues deserving attention. Agenda setting and time management do not only enhance the effectiveness of supervision, but in this era of accountability in clinical service delivery, they are essential skills for optimizing quality of clinical services within the constraints of limited budgets and staff resources.

Learning from (audio-) videotapes Videotape is the technology of choice in supervision (Bernard & Goodyear, 2004), although audiotapes may serve as back-up. The capacity to directly examine what actually occurred during superviseeclient interactions provides an important tool by which quality assurance can be achieved. Supervisees can be coached and validated with respect to specific therapist behaviours in the context of specific situations, rather than receiving feedback that is only as good as the general picture that is generated in the supervisor’s mind through the lens of the supervisee’s self-report. While the advantages for all stakeholders are obvious, supervisees tend to feel, at least initially, anxious and vulnerable



when using videotapes, as ‘‘there is no hiding from the stark reality of one’s picture and voice being projected into the supervision room’’ (Bernard & Goodyear, 2004, p. 219). However, evidence suggests that after repeated exposure to being videotaped these initial aversive effects dissipate quickly (Ellis et al., 2002). There are three simple steps that supervisees can take to get the most out of using videotapes, while guarding against any inclination to engage in avoidance behaviours for the short-term gain of reducing their sense of vulnerability. Selecting segments of tape

The first step involves the pre-selection of segments of tape that would be most productive to review. Although supervisors may at times review an entire tape prior to supervision, supervisees are encouraged to become actively involved in this process from the outset (Bernard & Goodyear, 2004). In deciding which segment to select for supervision, the supervisee can consider the following questions: 1. What part of the session seemed to be particularly productive? 2. What happened when I attempted to direct the session toward a specific goal as planned in supervision? 3. What part was I particularly struggling with? 4. Was there a part that I was confused about? 5. Was there a part that raised a particularly important issue or recurrent theme? 6. Was there a part during which I felt a strong emotional reaction? 7. Was there a part during which my client expressed or showed signs of a significant emotional reaction? 8. Was there a part where something occurred that made me change my plans for the session? Setting the stage

The second step involves succinctly introducing each video segment so that the supervisor is primed for what to expect and look for. Bernard and Goodyear (2004) recommend the following procedure for supervisees when presenting their pre-selected video segments: 1. State the reason for why you want to discuss this particular segment in supervision 2. State briefly what transpired up to that point 3. Explain what you were trying to accomplish at that point in the session 4. Clearly state the specific help desired from your supervisor.


Accounting for supervisory activities and outcomes Table 9.1. Impression management checklist.

1 2 3 4 5 6

Did I forget to bring my videotape to the supervision session? Did I forget to press record on the video recorder? Did I tape over the relevant session by mistake? Was part of the session missing because the tape had stopped? Did you bring the wrong tape with a different client’s session? Did you run out of time before you got to show the tape?

Yes h h h h h h

No h h h h h h

Guarding against impression management

The third step involves making a continuous commitment to contain counterproductive levels of evaluation anxiety. Consider the following checklist (Table 9.1.): If you find yourself answering yes on any of the above items more than once over the course of two or more supervision sessions, there is a strong possibility that you are engaging in counter-productive avoidance behaviours designed to reduce your fear of being vulnerable. If so, it is important to address this issue with your supervisor. The benefits of learning from moment-to-moment analysis of videotaped clientsupervisee interactions far outweigh the concerns. Accounting for supervisory activities and outcomes Standards of practice in most mental health disciplines stipulate that written records be kept of supervisory contracts and supervisee evaluations (Falvey & Cohen, 2003). In addition, there are at least four reasons why it is good practice to document activities and outcomes of supervision sessions. First, documentation of supervisory decision processes, recommendations and outcomes affords some protection for supervisors who may be held liable for a supervisee’s harmful actions. Second, it is a structural tool that brings into focus the deliberate nature of science-informed, reflective practice. Third, it provides the data for a proactive model of monitoring client progress, which can be used to modify treatment plans that appear to be ineffective (Lambert & Hawkins, 2001). Finally, the process of systematic and regular documentation reduces the risk that supervisees feel overwhelmed with the complexities of their cases, fail to implement key interventions in a timely manner, or overlook critical aspects of case management (Lambert & Hawkins, 2001). Various templates have been developed for documenting supervision activities and outcomes (e.g. Bridge & Bascue, 1990; Falvey & Cohen, 2003). An example



Figure 9.3.

Supervision record form

of a Supervision Record Form is presented in Figure 9.3. The form begins with a section to record the supervisee name, client ID, date of supervision session, and information on frequency and type of client contact. The next few sections document the activities central to a goal-directed, reflectivity-enhancing, competency-based approach to supervision. First, the supervisee’s specific agenda items are listed, along with previous session goals and progress on achieving them. The next item adds context (or the big picture) in terms of


The challenge to advance beyond the familiar

overall progress on the primary treatment goals. Then any relevant new issues that have arisen in the work with the client are recorded. This is followed by an explicit statement of what is planned for the next session. Finally, a separate section focuses attention on risk management issues and the steps taken to address them. Group supervision The proactive, structured and goal-oriented activities associated with agenda setting, purposeful examination of supervision data, and documentation of supervision interventions and outcomes are equally applicable whether supervision is delivered in an individual or group format. One often cited potential limitation of group supervision (Bernard & Goodyear, 2004), that individuals may not receive sufficient time to address all their individual concerns, is a case in point. There is little risk that supervisees who turn up to group supervision prepared, who have prioritized the issues that must be attended to before supervision ends, and who routinely document feedback and recommendations for these issues, will get less of what they need during group supervision than during individual supervision. Likewise, although there may be more opportunities for confidentiality concerns and unhelpful personal interactions to emerge when several individuals are involved rather than just two (Bernard & Goodyear, 2004), these problems can arise and require resolution in both formats. Moreover, when a supervisee experiences discomfort in a particular interaction with a supervisor, the presence of peers in the same room can be comforting and reduce supervisee dependence on the supervisor, and peers can be helpful in validating the supervisee’s perspective during or after the event. In addition, there are a number of other advantages of the group format, including opportunities for vicarious learning, exposure to a broader range of clients, increased diversity of feedback, and greater resources to use action techniques. The modelling literature emphasizes that models of coping are better than models of mastery, and therefore, watching one’s peers and senior students can be beneficial. Therefore, the assumption that individual supervision is inherently superior is not only a myth (Bernhard & Goodyear, 2004), but the efficiency and advantages of group supervision may soon make it the format of choice as demands for enhanced efficiency and flexible formats in a competitive healthcare market are increasing (Milne & Oliver, 2000). The challenge to advance beyond the familiar The ultimate goal of supervised practice is for the supervisee to achieve competency as a clinician and readiness to assume the role of a colleague who



independently contributes to the community and the discipline (Falender & Shafranske, 2004). The rate at which beginning supervisees increase the proficiency with which they apply complex therapy procedures and facilitate internal therapeutic processes varies considerably across individuals. The novice typically experiences high anxiety, is self-focused, is preoccupied with performance of techniques and following guidelines, and worries about evaluation (Stoltenberg & McNeil, 1997). Supervisory guidance during this period is therefore highly supportive, structured and prescriptive. It focuses on consolidating basic strategies rather than challenging supervisees to quickly expand their repertoire of techniques beyond the trusted and familiar. As client contact increases and supervisees experience some successes in implementing planned interventions, their initial sense of incompetence gives way to a sense of accomplishment and even pride. At that point, supervisees must guard against getting stuck in this comfort zone, where a set of rudimentary skills may help a client or two and stave off disaster, but is inadequate for functioning within the full scope and demands of independent clinical practice. Indeed, early adoption of only one particular therapeutic approach or a rigid set of skills can lead to frustration with situations not fitting that narrow range of skills, and ultimately to professional stagnation or failure (Neufeldt, 2003). The challenge for supervisees is to remain flexible and open when prompted by their supervisors to use each increase in their competence as a platform for pushing off toward the next level of professional development. Venturing into unfamiliar territory will temporarily revive feelings of insecurity, but this is a small price to pay for the rewards associated with gaining mastery over an advanced repertoire of complex skills.

Formative and summative evaluation Bernard and Goodyear (2004) described evaluation as the nucleus of clinical supervision, because it simultaneously supports the learning process, case management, and quality client care. Formative evaluation is ongoing and involves direct feedback on the supervisee’s professional growth and effectiveness in performing clinical services. This may take the form of formal reports at certain intervals (e.g., at the end of each rotation or period of working with a given supervisor), or informal, frequent feedback during each supervision session. In contrast, summative evaluation refers to ‘‘the moment of truth when the supervisor steps back, takes stock, and decides how the trainee measures up’’ (Bernard & Goodyear, 2004, p. 20). Anticipatory anxiety about receiving summative evaluations can be quite distressing to supervisees. However, supervisees


Learning supervisory skills

should bear in mind that the criteria used during summative evaluation are the same that were introduced at the outset of supervision as learning objectives, and that were used to provide intermittent formative feedback throughout their supervision. That is, if there was no clear indication during formative evaluation that a supervisee’s performance was consistently below standard, then the supervisee should rest assure that summative evaluation will not be suddenly negative. Supervisors have an ethical obligation to apply due process procedures before a supervisee is given a negative final evaluation (Bernard & Goodyear, 2004). This involves providing the supervisee with sufficient prior warning, specific remedial advice and a reasonable period of time to improve. The more supervisees get actively involved in the formative evaluation process, the less daunting summative evaluation becomes. For the reflective supervisee who established a habit of self-scrutiny and responsibly documenting their supervision activities and outcomes, it is only a small step to also self-evaluate their own work using the same criteria as the supervisor. Not only will that prepare the supervisee for the summative evaluation process, but the skill of accurately assessing one’s own strengths and weaknesses is critical for ongoing professional development and could be regarded as a prerequisite for anyone engaging in the supervision and evaluation of others.

Learning supervisory skills Novice therapists are likely to give little thought as to what skills are needed to shift from the role of direct service provider to the role of supervising someone else to be the best service provider they can be. Yet, their experiences as consumers of supervision combined with the modelling by different supervisors function as tacit training in the practice of supervision itself (Falender & Shafrankse, 2004). Until recently, such implicit models of training supervisors were the norm, with a substantial proportion of supervisors having received no formal education and training in supervision (Johnson & Stewart, 2000; Spence et al., 2001; Townend et al., 2002). It is now increasingly recognized that training programmes should include and enhance formal training in supervisory skills (Bernard & Goodyear, 2004). Novice therapists, of course, are not expected to already undertake hands-on supervisor training while their energies are still directed toward making their own fledgling steps as therapists. However, some basic supervisory skills are already relevant even to novice supervisees (for example, if they are involved in group supervision), and certainly to more advanced trainees who are involved in peer- or co-supervision under the guidance of an experienced supervisor.



When thinking about what it takes to become a supervisor, it is helpful to start by clarifying what a supervisor is not. First, the supervisor is not the therapist of the client. That is, the supervisee is not a surrogate for the supervisor as clinician. Second, the supervisor is not the therapist for the supervisee. The supervisee’s personal issues are only addressed to the extent that they bear directly on clienttherapist or therapistsupervisor interactions. Consider a trainee who is getting very emotional during a session with a client who relates feelings of guilt and distress regarding her indecision to abort her unborn child or to keep it. If reflective inquiry reveals that the supervisee’s strong discomfort was related to her own past experience of an unplanned pregnancy, then the supervisor would focus on helping the supervisee figure out how she can be helpful to her client (from her client’s perspective!) without letting her own emotional reactions get in the way of that task. In contrast, if it becomes apparent that the supervisee struggles to separate her own distress and needs from that of the client, and that she might benefit from personal therapy to better cope with the personal issues raised by this event, then it would be unethical for the supervisor to act as her therapist. Thus, when making the transition from clinician to supervisor, the focus shifts from exploring the meaning of an event to the way in which this event might affect the supervisee’s work with the client (Neufeldt, 2003). In sum, the acquisition of beginning supervisory skills involves getting past being a clinician and attending to (a) the supervisee’s learning, (b) one’s own managerial competence to facilitate (a), and (c) the ethical obligations that arise when advanced trainees contribute to the supervision of more junior peers. Advanced trainees can facilitate the learning of more junior supervisees by applying supportive, reflective and prescriptive strategies. Supportive strategies

. Provide praise and encouragement. Highlight any aspects that the trainee did

well. Acknowledge that doing things for the first time is difficult. Help shift the focus from what went wrong to how to do better the next time. . Be respectful and tactful when commenting on things that did not go well. Reflective strategies

. Examine the trainee’s behaviour. Ask the trainee to explain how a given

behaviour does or does not serve the intention of the trainee at the time, the goals for this particular session and the overall treatment goals. . Ask the trainee to generate hypotheses about the client’s behaviour, thoughts or feelings. Consider a client who informs the therapist that her 16-year-old son is going to leave her in the near future to live with his father in another


Learning supervisory skills

state, and then remarks quickly that she is ‘‘OK with this’’. Encourage the trainee to suggest several options what the client might be feeling about the upcoming event (e.g., does ‘‘it is OK’’ mean ‘‘it is not very painful’’ for the client, or does it mean it is very painful, but ‘‘I will manage’’, or does it mean ‘‘I am not OK’’, ‘‘I will be lonely’’, ‘‘I am afraid, my son won’t talk to me anymore’’?) . Explore the trainee’s feelings during client and supervision sessions. Ask in what ways these feelings can hinder or help working with the client. . Help the trainee to plan ahead. Encourage the trainee to make predictions about which hypotheses about the client are most likely given what the trainee already knows about the client’s circumstances and history. Then suggest testing that prediction in the next session. Prescriptive strategies

. Offer alternative interventions or conceptualizations for the trainee to use . Explain and/or demonstrate how to use intervention techniques

Bernard and Goodyear (2004) noted that one particular benefit of receiving feedback from fellow advanced trainees is that they are closer to their own recent experiences as novices than the senior supervisor is. Therefore, their explanations may at times be easier to follow than those of the expert. In addition to facilitating novice supervisees’ learning, advanced trainees can increase their managerial competence by taking an active role in structuring the supervision session, facilitating good time management, and keeping records of their supervisory activities. Finally, advanced trainees must be aware of their ethical obligations when they participate in the supervision of more junior peers. This includes maintaining a professional distance from the junior colleagues they are supervising, which can pose a challenge within the small community of a training programme where students interact in classes, research teams, and social activities. However, dual relationship problems can be avoided by observing a few simple guidelines. Neufeldt (2003) recommends that (a) role obligations are clarified from the outset, (b) supervisory activities remain confidential and there should be no gossip about supervisors or supervisees, and (c) advanced trainees should not supervise a peer who is a room-mate, close friend or romantic partner. In general, when considering dual relationships between a supervisor and trainee, the supervisor’s needs are subordinate to the needs of the supervisee and the needs of the supervisee’s clients (Falender & Shafranske, 2004). Any benefits derived from such relationships must be weighed against the imperative to minimize the potential for harm. A useful decision-making model by Burian and Slimp (2000) raises awareness of the issues and circumstances to be



considered when contemplating the merits and risks of engaging in social dualrole relationships between supervisors and trainees. The first question to consider is the reasons for engaging in the relationship. A dual relationship may have merit if there are professional benefits to the trainee or supervisor. For example, conducting workshops together may involve planning meetings, lunches, or a social gathering with workshop attendees for a drink at the end of the day. As long as the purpose of the social activities remains focused on workshop-related activities and associated professional benefits for both persons involved, the risk of harm is minimized. In contrast, a social relationship should not proceed if it only has personal benefits to the supervisor, and should only proceed with caution and after careful consultation if it is primarily of personal benefit to the trainee. The second question to consider is the degree of power the supervisor has over the trainee. A possible social relationship is best postponed until a time when the supervisor has no evaluative role, either directly or indirectly, with respect to the trainee. The third question to consider is where this social relationship takes place. If the social contacts are in the context of the work site and are not exclusive of others who may wish to join the social interaction, the potential for harm, such as the perception of favouritism, is reduced. In addition to considering these three basic questions, before deciding to pursue a social dual-role relationship, it needs to be established that the trainee has the ability to leave the social relationship or activity without repercussions, and there is no negative impact on uninvolved trainees or staff members. However, supervision is not the only context where difficult situations arise. More often than not, tricky situations arise within the course of consulting with a client. Supervision is a key component in responding effectively to problems during therapy. One such common problem is treatment non-compliance or therapeutic resistance, and it is to this topic that we now turn.


Managing treatment non-compliance

Consider beginning a treatment session with an anxious client, who you had given the task of completing a diary with a fear thermometer (i.e., rating anxiety on a 0100 scale) along with a record of any anxiety-provoking situation, any unhelpful thoughts, and subsequent feelings. The session opens like this: Psychologist Client P C P C

How have things been going this past week? Pretty good. I’ve been doing what you asked me and I’ve noticed that the anxiety is a lot less than it was. In terms of the fear thermometer that you were using each day to rate your anxiety as homework, what sort of ratings did you get? Well I didn’t put them in my diary, but I thought about it each day and I’ve remembered my ratings. That’s OK. But it would be really good if you did it next week instead because it might show something useful. Yeah, no problem at all.

In subsequent sessions, if this pattern continues, it will become entrenched with the client not ever bringing any homework to the sessions. Ultimately, the client may terminate therapy leaving you to lament that if the client had been more motivated, treatment would have had a more positive outcome. Could anything have been done differently to increase compliance with treatment? A model of resistance and non-compliance Reviewing our model of clinical practice (see Figure 10.1), it is apparent that in normal circumstances there is a flow of information from one element within the model to others. However, when these links are broken, clinical practice has the potential to break down. Some of these links can be affected by actions that are more under the control of the psychologist than the client and many of these have been considered in previous chapters. For instance, failing to conduct an


Managing treatment non-compliance

Figure 10.1. Interference in the clinical process by client resistance and non-compliance

adequate assessment or case formulation can undermine effective treatment planning. Poor treatment planning can in turn result in the implementation of potentially inappropriate, ineffective or inefficient therapies. Likewise, failing to monitor progress towards treatment goals or to measure outcomes can lead to unnecessarily long persistence with an ineffective or counterproductive therapy. However, there are other points at which psychological practice can be disrupted by activities that appear, at first glance, under more control of the client than the psychologist. The client may fail to disclose all the relevant information, thereby hindering case formulation and weakening the value of pre-treatment assessments. A client may also be non-compliant with therapeutic suggestions and exhibit resistance within psychotherapy. Such non-compliance with the treatment strategies will hinder implementation and reduce the ultimate success of any intervention. The focus of the present chapter will be twofold. We will discuss client behaviours that can have a negative effect on treatment outcomes, and we will review strategies how the psychologist can deliberately exert influence over the therapeutic relationship to minimize the hindering impact of these client


What is therapeutic resistance?

behaviours, even though many of the relevant client behaviours will not be under the clinician’s direct control.

What is therapeutic resistance? Definitions of therapeutic resistance vary depending on whether the source of the client’s resistance is construed as residing within the client or as being triggered by something the therapist does or fails to do. Lazarus and Fay (1982) suggested that the notion of client resistance is, ‘‘the most elaborate rationalization that therapists employ to explain their treatment failures’’. These writers place the responsibility for the non-compliance in the lap of the psychologist. Accordingly, the non-compliance may be illusory and an interpretation by the psychologist to rationalize therapeutic failures, or it may reflect the fact that client and psychologist have disagreed about the outcomes. In contrast, other writers place the responsibility with the client. For instance, Wachtel (1982) defines resistance as occurring when, ‘‘the sincere desire to change confronts the fears, misconceptions, and prior adaptive strategies that make change difficult’’. Implicit in this latter definition is the notion that ambivalence toward treatment lies at the heart of client behaviours that manifest as resistance and noncompliance. Later in this chapter, we will review strategies that help clients shift from being stuck in a state of ambivalence by enhancing the value of changing relative to the benefits of not changing. Reflecting upon these different approaches to defining resistance in therapy, it is evident that they are not mutually exclusive. It is conceivable that a therapist may rationalize a failure or unintentionally act in ways that impede therapeutic progress. It is also plausible that a client may fail to engage in the activities designed to bring about therapeutic change. Thus, it is not very helpful to debate in the abstract who is to blame. It is more fruitful to consider how to manage resistance and non-compliance when it becomes a hindrance to achieving positive treatment outcomes. We suggest that the clinical psychologist should take responsibility for dealing with resistance (without necessarily taking the blame for poor therapeutic outcomes). That is, the psychologist is a professional who is providing an expert service and part of that service is being able to deal with hindrances to a positive outcome. By way of analogy, consider a school teacher trying to teach an uncooperative 14 year old. Good teachers will not blame the child, but see the situation as a problem to be solved and they will accept responsibility for attempting to find a solution. It will not help the student to blame him for not learning, or just to give up and accuse him of being uncooperative (even if this


Managing treatment non-compliance

is true). Good teachers will look for ways to help the child to learn by overcoming the resistance rather than using resistance as a reason or an explanation for a failure to learn. Thus, we view therapeutic resistance as an issue to be addressed in the overall treatment plan, not as an explanation for therapeutic failure. In taking a problem-focused approach to resistance, we are also adopting a trans-theoretical approach to resistance and non-compliance. The trans-theoretical perspective is important because psychodynamic and family therapists may view the exploration of resistance as a critical ingredient for intervention, whereas cognitive and behavioural therapists tend to view resistance as a problem that must be dealt with so that therapy can return to its primary objectives. Our approach is a pragmatic one; the goal is the amelioration of the client’s problems, and the clinician’s job is to help the client achieve this goal. To the extent that resistance and non-compliance interfere with this goal, they need to be addressed during treatment.

Managing resistance during different phases of the therapeutic process During the assessment phase

During the initial assessment there are a variety of ways that a psychologist can reduce the probability of therapy-interfering behaviours arising. First, contacting the client before the first session will increase the probability that the client will attend for the initial contact. Second, it is important to establish your credibility as a competent professional who can create the context for change. At first glance this presents a dilemma to novice psychologists who will dread the question from their initial clients, ‘‘how many people have you treated with problems just like mine?’’ How do you establish credibility in the absence of years of experience? One way to enhance credibility is by preparing thoroughly and drawing on the collective expertise of the setting within which you are working (e.g., you might respond, ‘‘I have not treated anyone with this problem before, but we have been using these treatments with success in this clinic for many years’’.) Your credibility will also be conveyed in the professional manner in which you interact with your client, such as dealing with the referral promptly and efficiently, having relevant materials to hand, and so on. In maintaining a credible demeanour, it is important to remember that although you may feel inexperienced, you have had many years of training in psychology and your knowledge base of normal and abnormal behavioural patterns will be substantial. Therefore, try to focus on what you do know, rather than worrying about the things that you might not yet know. Finally, credibility is enhanced most by honesty and integrity in communication. Therefore, communicating accurately


Managing resistance during different phases of the therapeutic process

your expertise and experience in response to an enquiry will facilitate the therapeutic relationship more than trying to bluff your way through. A third way to reduce the probability of therapy-interfering behaviours is to begin treatment by rapidly establishing good rapport with clients using the techniques outlined in Chapter 2. Fourth, non-compliance can be reduced by modelling good listening behaviours. Allow your client to finish each statement and reflect back both the informational and the emotional content. In so doing, ensure that you permit your client to express emotions fully. Fifth, when you are ready to use assessment procedures, take time to provide a clear rationale for the tests and give strong encouragement about completing the procedures. When the assessment process is finished, reward the clients for their efforts put into completing the assessments by providing them with clear and informative feedback. Sixth, employ strategies that increase the engagement of the client in therapy. It is possible to increase the engagement by gaining an explicit commitment to complete assessment, then treatment, and finally follow-up. These commitments or contracts are obtained in a sequential manner, so that you are just asking the client to commit to the next phase in the process of therapy. Seventh, if appropriate, engagement can also be enhanced by maintaining contact with the client between sessions with the aim of asking how things are going, checking that there have not been any difficulties with the homework assignments, and gaining a commitment to attend the next session. Finally, given the important role of homework compliance (Kazantzis et al., 2000, 2005; Kazantzis & L’Abate, in press), it is necessary to reinforce the completion of any assignments, a point that will be discussed in greater detail below. During the implementation phase

Once treatment has begun, the psychologist can continue with many of the strategies described above and some other strategies can be added. First, articulating a clear, shared formulation of the problem and an explicit rationale for treatment is likely to increase the engagement of a client (but cf. Chadwick et al., 2003). Second, client engagement can be fostered by conveying optimism about change, which can be achieved by citing data on the probability of success and by identifying the factors that predict improvement. For instance, you might comment, ‘‘we know that 2/3 of clients are improved to the point that they no longer meet diagnostic criteria for the problem that they sought help for. However, you might be thinking to yourself, ‘I bet I’m in the 1/3 of therapy failures’. But we know from research the reasons why people find themselves in the 1/3 of people who don’t succeed so well. One of the main factors is not complying with the treatment. Thus, the good news is, the harder you work in


Managing treatment non-compliance

the programme, the more likely it will be that you will be one of the 2/3 who succeeds’’. In addition to citing research evidence, optimism about change can also be enhanced by establishing a collaborative set. For instance, you might add: ‘‘Also, I don’t see therapy as a process where I sit on the sidelines watching you succeed or fail. I see my role as working with you all the way, overcoming obstacles, and doing everything I can to ensure that together as a team, we can collaborate to help you overcome this problem’’. Third, client engagement can be enhanced by anticipating possible obstacles to treatment. The process of case formulation described in Chapter 4 provides a mechanism for identifying a client’s weaknesses that may adversely impact on outcomes, as well as the client’s strengths and resources that may be drawn upon to attenuate any adverse effects. Fourth, when resistance or non-compliance is blocking the process of treatment you may decide to raise the issue with the client explicitly (perhaps preferring to use less judgemental descriptions, such as ‘‘something appears to be blocking our progress’’ or ‘‘we seem to be encountering some difficulties in taking the steps we agreed would be helpful at this stage’’). Work with the client to identify the meaning and function of the resistance, and then respond accordingly. Some examples of resistance are outlined below: . The psychologist might describe a therapeutic technique and the client refuses to comply, claiming that she does not understand what to do. This problem may have arisen because the therapist has miscommunicated or the client has difficulty comprehending. The response would be that the psychologist would re-present the technique, using different words than before, drawing upon examples and metaphors to assist comprehension. . The client might appear unmotivated due to a lack of expectation of success. The psychologist could identify the reasons why the client has formed this view, clarify any misconceptions or unrealistic expectations, and then identify the probability of success and demonstrate which of the predictors of a favourable outcome the client possesses or are present in the environment. . The client might be making unusually slow or erratic therapeutic progress. This could arise from any number of causes and so the psychologist should review the case to ensure that all the problems have been identified, the treatment is appropriate for the problem and the particular type of client. If these possible causes are not reasonable explanations, then the psychologist could consider other explanations, such as that the client’s problem serves a function or meets a need that would remain unmet if the problem was ameliorated. For instance, the client’s familiar problem may maintain an uneasy but reassuring balance within a family structure, whereas change in the client would disrupt this balance, and the need to adapt to this unfamiliar situation may be perceived as too hard or distressing. Consider a client who


Managing resistance during different phases of the therapeutic process

after making successful progress in overcoming her agoraphobic avoidances reported that her partner was complaining that he did not like her new-found freedom. He was no longer sure that she was at home and hence worried that she might be forming relationships with other men. He did not like the fact that his dinner was no longer on the table when he walked through the door because his partner had been busy with other activities during the day. In this case, these issues did not necessarily cause the problem in the first instance, but interfered with progress by weakening the client’s resolve (albeit temporarily) to overcome the agoraphobic avoidances. It is also possible a client is slowing down progress deliberately to test the psychologist. For example, a client with a fear of abandonment may observe the psychologist’s reaction to his failure to progress, waiting to see if the psychologist will, ‘‘dump him, just like all the other shrinks’’. In these cases, the reasons for noncompliance need to be explored as possible causes or maintaining factors in the problem and dealt with accordingly. . Another scenario is when the client will present with a meaningful behavioural pattern or sequence that is a manifestation of avoidance behaviour. A client may behave in the relationship with the psychologist in a manner than acts out some aspect of the presenting problem. For instance, a client who fears negative evaluation in performance settings could well view therapy as a social performance within which he is required to behave in a certain way, and if he fails to do so, then the psychologist will judge him negatively as a bad patient. In this case, the psychologist would address the client’s fear of negative evaluation and could use the manifestation as an opportunity to bring the problem into the therapy room and deal with it as the behaviour unfolds. Finally, non-compliance during treatment can result from the client deliberately challenging the therapist. When this occurs, it is wise not to be defensive, but to make the concern explicit, and to deal with the challenge by addressing it. Sometimes the situation can be defused through humour (although this has the potential to backfire if the client interprets a humorous retort as belittling them or their concern). At other times the concern can be dealt with by matterof-factly citing appropriate data. If a client’s challenging style continues to a degree that a cooperative working relationship cannot be maintained, it might be appropriate to refer the client to another therapist. During the termination phase

Considering termination there are a number of ways to increase compliance with the preparatory steps to facilitate an end of formal therapeutic contact. Addressing termination in an explicit manner is important. This allows the client to plan for termination, to deal with any grief and loss which may


Managing treatment non-compliance

be experienced, and to raise any further matters which should be dealt with before termination is complete. Phasing the last treatment sessions so that they are spaced at greater intervals can be beneficial, as can scheduling a formal follow-up session (so that the client does not feel abandoned at the end of treatment). It is also useful during the latter phases of treatment to reinforce independence and discuss relapse prevention strategies. This will help to develop the client’s self-efficacy that they are now able to continue to implement and apply the lessons and skills learned in therapy even after therapeutic contact has ceased. Clients who are confident that they will be alright after completion of therapy are not prone to show non-compliant stalling behaviours as the end of therapy approaches. Sometimes the clients’ confidence can be undermined by unhelpful cognitions they hold. Cognitive behaviour therapists have suggested that the clinician can engage in a search and destroy (Jacobson, 1984) approach. During the search phase, the psychologist tries to identify cognitions that may be impeding termination planning. Once possible cognitions are identified, the clinician proceeds to construct behavioural experiments to test the validity of these cognitions, with the ultimate goal of disputing these cognitions. For example, one of us saw a client who became distressed at the prospect of termination, despite having made substantial progress. Careful interviewing revealed that the client was concerned that if he lapsed back into problem drinking, then there would be no way to access therapeutic assistance. Therapy then shifted to address these beliefs; examining the nature and consequences of termination, reviewing the skills attained, practicing relapse prevention strategies, and clarifying ways to access future therapy if required.

Managing resistance by enhancing motivation Often it is useful to not label resistance as a problem as such, but instead to reframe resistance as an understandable process common in many people seeking treatment. The psychologist could identify benign explanations for resistance and seek to side-step a direct confrontation. For instance, instead of treating ambivalence about continuing in treatment as an absence of motivation, the psychologist could discuss how ambivalence is a natural response to the simultaneous presence of approach and avoidance motivations. When either approach or avoidant motivations dominate, then the behavioural outcomes will be clear, but when approach and avoidance motivations are similarly strong, ambivalence will occur. This can be reframed as a good state to be in, because it is evidence that the client still sees enough value in treatment to not have simply


Managing resistance by enhancing motivation

dropped out. The focus of therapy can then shift towards an evaluation of the twin motivations and seek to tip the balance in favour of continuing to engage in treatment (cf. Breiner et al., 1999). Arguably the most helpful and readable book on this topic is Miller and Rollnick’s (1991; 2002) Motivational Interviewing. One of the important contributions that this book makes in the present context, is the acknowledgement that motivation is not an issue that is constrained to the initial assessment, at which time the psychologist judges to what degree motivation for change is present or absent. Instead, motivation is to be recruited at all points throughout therapy to get and to keep the client engaged with treatment. In particular, motivational interviewing is especially relevant to clients who are ambivalent about treatment. Clients with substance use problems typically fall into this category, but many other clients are ambivalent too. For example, anxiety-disordered clients often begin treatment highly motivated, but once the prospect of confronting feared situations emerges, the client can become scared and ambivalent. In addition, clients may have participated in failed treatment attempts and hence are ambivalent about the value of the present intervention, especially if it is similar to one that has already been tried. Clients may also be ambivalent about treatment if their relationships are threatened by the prospect of successful treatment or if undesirable consequences follow amelioration of the problem. For instance, clients may derive social support and reassurance as a consequence of having problems and recovery may put an end to such secondary benefits of the status quo. To counter the negative impact of these hindrances on treatment compliance, the task of the clinician is to ensure that the person’s motivation for treatment is maximized and remains sufficient to propel the individual to a successful completion of the treatment programme. To this end Miller and Rollnick (2002) identified five general principles of motivational interviewing which can be applied fruitfully to a broad range of presenting problems, not just addictive behaviours. The five principles are expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self-efficacy. Expressing empathy

People who suffer with psychological problems frequently complain of being misunderstood. For instance, a person suffering from obsessivecompulsive disorder may finally bring themselves to describe their uniquely terrifying experiences to another, only to be frustrated with the responses. Trite advice may be forthcoming (e.g., ‘‘You must be uptight, why don’t you just relax?’’), or even worse, sympathy is offered (e.g., ‘‘I check too. When I leave my car I check I haven’t locked my keys in. I really understand how you must feel’’). Therefore,


Managing treatment non-compliance

it is imperative that the individual feels from the psychologist’s first utterance that their complaint has been heard. An empathic response responds to the meaning and emotion expressed in a communication, all the time accepting the validity of the person’s experience. For instance, a person describing the experience of a panic attack is usually trying to communicate an occurrence of fear which is perceived to be qualitatively different from any anxiety, worry, tension, or fear which they have experienced before. In addition, they often conclude on the basis of this experience that the event must be unique and an indication of a serious physical or mental problem. By extension, the person is communicating that, although they have previously been able to manage anxiety in all its forms using various coping strategies, this is different; these attacks of panic are uncontrollable. An accurately empathic response accepts the validity of the person’s experience, leaving the person with the perception that the listener has heard what has been said. These principles which underlie empathic communication are illustrated by contrasting two clienttherapist interactions, where one does not include an empathic response (Psychologist 1) and the other does (Psychologist 2). Client

Panics are the most terrifying experience I have ever had. Have you ever had a panic attack? Psychologist 1 Yes, I think I have. It was during the war when we were under enemy fire . . . Psychologist 2 I’ve been anxious before, but it sounds as if you have found panic attacks to be quite different from the anxiety that you used to feel. The first response is less helpful because the therapist fails to identify with the client’s experience. The client is testing to see if the therapist understands the uniqueness of their experience of panic, but the therapist does not respond to this theme. Instead, the psychologist moves to relating personal experiences that may or may not be relevant, but thereby shifting the focus from the client to the therapist. The second psychologist draws attention to the qualitative difference sufferers perceive between anxiety and panic. Such a response is preferable because it draws attention to the uniqueness of the experience and returns the interview to the client’s concerns. Client

When I’m having a panic all my rational thoughts go out the window and I think I AM going to die of a heart attack. Psychologist 1 But you have had many clean ECGs, your cholesterol is low, and you are young. Everything points against you actually dying of a heart attack.


Managing resistance by enhancing motivation

Psychologist 2 It makes it difficult to stop the panic when the worry about dying becomes so overpowering. The first psychologist jumps in to offer premature reassurance. But the client is not saying that she really believes that she is dying, only that the panic appears to rob her of her rational powers. The second psychologist responds to this comment by reflecting the meaning conveyed. It is the second response which will lead to the client continuing the interaction with the accurate perception that the psychologist has heard the communication. Client

I’ve had this problem for ten years, I’ve been to so many different psychologists it is not funny, and I haven’t got better so far. Psychologist 1 Well, we use a cognitive-behavioural programme which is very successful and I’m very experienced in delivering the technique. You should improve quickly. Psychologist 2 Having failed before it must have been hard to bring yourself along to the clinic. What made you decide to try again? The first psychologist responds to the client’s implied doubt about whether psychological treatment works for her by presenting therapeutic credentials. In contrast, the second psychologist perceives the deeper issue and draws the person’s attention to the motivation which was recruited in order to re-engage in treatment. Having done so, the psychologist will be in a position to build upon the person’s existing motivation to engage in treatment. Importantly, the second psychologist implicitly acknowledges that ambivalence about treatment is normal and models that building on existing motivations is a useful therapeutic strategy. In summary, expressing empathy involves accurately responding to the meaning and emotion in a communication in such a manner that the other feels understood. Developing discrepancies

Accepting the validity of a person’s experiences does not necessarily involve accepting that clients stay as they are. To the contrary, the purpose of offering empirically validated treatments is to modify maladaptive cognitions and behaviour. But encouraging change should not involve vigorous confrontation, as this can lead to alienation of the client (Miller & Rollnick, 2002). That is, while the goal may be to produce an awareness of the need for change, direct verbal challenges may not be the best way to achieve this goal. A better strategy is to


Managing treatment non-compliance

focus on developing a discrepancy between the person’s current behaviour (and its consequences) and future goals. Every client presents to treatment with some degree of ambivalence. The task is to ensure that the rewards of recovery outweigh the benefits associated with maintaining the status quo. By drawing attention to where one is, in relation to where one wants to be, it is possible to increase awareness of the costs of a maladaptive behavioural pattern. Importantly, it is necessary to focus upon costs that are seen as relevant to the client rather than the psychologist. For instance, one of us mistakenly suggested to a person with agoraphobia that her child might be pleased and proud when she could be taken on the train into the city, only to face the response, ‘‘I know I should want to get better for my kids, but I don’t. Everyone says I should, but I can’t seem to care’’. Instead, for this client the most salient motivation was the freedom to be able to go to the local shops while unaccompanied. Once this goal was identified it was possible to use it as leverage to further enhance the value of personal freedom relative to the value of anxiety reduction during shopping outings that is contingent upon reliance on others. The greater the discrepancy is between these competing values, the greater is the motivation for change. One way to develop discrepancies between current behaviour and future goals is to enquire about what the person would most enjoy doing when unshackled from their panic disorder or agoraphobic avoidance. When this image has been developed, it can be contrasted with the person’s present state. The resulting dissatisfaction with the status quo can then be used to motivate the person to engage in therapeutic activities. In summary, all clients are ambivalent about treatment to varying degrees. To enhance motivation it is useful to develop a discrepancy between clients’ current behaviour and their desired state. By increasing the perceived value of changing relative to the perceived benefit of staying the same, the balance can be tipped toward greater treatment compliance.

Avoiding argumentation

Once a person initiates treatment and begins to comply with the components of the programme setbacks invariably occur. An unsatisfactory way for a psychologist to respond is to harass the person to complete an exercise or berate the person’s non-compliance (quietly cursing the client’s passive aggressive personality disorder). Miller and Rollnick (2002) suggest that it is more profitable to avoid argumentation. They encourage the view that therapeutic resistance is not so much a signal of client failure, but a signal for the psychologist to shift strategy. Resistance is a problem which the psychologist


Managing resistance by enhancing motivation

must take the responsibility to solve. The shift towards problem solving enables the psychologist to avoid argumentation and roll with resistance. Rolling with resistance

Therapeutic resistance may signal a lack of understanding of the purpose of part of the programme or it may indicate a lack of success with one of the treatment components. Resistance may also indicate a weakening of resolve, indicating the need to develop a discrepancy to once again enhance motivation. Whatever the case, the psychologist must back-track and solve the problem. Regardless of the origin of the difficulty it is necessary to avoid argumentation and roll with resistance. Rather than pushing against the resistance, the therapist can extract from the complaint or refusal a foundation of motivation upon which to re-build the treatment. Consider the following examples of therapeutic interactions. Client

I’m having a bad day with my agoraphobia. I don’t think that I can do today’s assignment. Psychologist 1 You have to face your fears. Remember, avoidance makes fears worse. You will just have to go out and catch the bus. Psychologist 2 When we agreed to the assignment yesterday you felt that it was achievable. What do you think it takes for you to achieve the task? Both psychologists have the same goal in mind; they want to motivate the person to complete the agreed assignment. The first psychologist pursues this goal by reinforcing good reasons for attempting the assignment. Even though the reasons are valid, they are sub-optimal for two reasons. First, they encourage refusal from the client, leading to a possible confrontation. Second, the response indirectly encourages dependence upon the psychologist for the recruitment of motivation necessary for task completion. When treatment is terminated the client will no longer have the psychologist’s support and therefore the aim is to encourage client autonomy. In contrast, the second psychologist encourages the client’s autonomy by asking the person to find a solution. While the psychologist would obviously provide assistance, the goal is for the client to identify why the task is no longer achievable and how these obstacles can be overcome. As part of rolling with resistance it is useful to implicitly convey the expectation that the client has the resources necessary to achieve the task. For this reason the second psychologist did not ask how the task could be made more simple (which may implicitly convey that the task is too difficult), but shifts attention towards how the task can be achieved. While the latter approach may involve


Managing treatment non-compliance

breaking the step into a series of graded easier steps, the psychologist conveys an expectation that the task is achievable. Client

I did everything right, but I still find myself having panic attacks. Your treatment just isn’t working. Psychologist l We know the treatments are effective, what do you think you did wrong? Psychologist 2 Even though you battled hard to manage your anxiety, the panic still breaks through. Are there any lessons that you can learn to help you have greater success next time? The client is expressing frustration that despite the best effort, the treatment techniques appear to be ineffective. The first psychologist responds by drawing attention to the person’s possible poor conduct of the technique. Although clients may have difficulties because they fail to use the treatment techniques appropriately, it rarely helps to direct blame towards the client. Instead, the second psychologist empathically acknowledges the frustration but directs attention to the future. Implicitly the psychologist is communicating that setbacks are not a reason to throw in the towel, but an opportunity to learn. The second psychologist also implicitly assumes that the client is going to continue to work towards managing panics. Probably both psychologists would identify the same problems in performance. However, the second does not oppose the resistance. Rather, the psychologist rolls with the resistance, arriving at a position where motivation can be evaluated and practical strategies to attempt the next assignment can be identified. In summary, argumentation can be avoided if one rolls with therapeutic resistance. In doing so it is helpful to respond to resistance with a shift in strategy to problem solving. The psychologist always implicitly conveys the knowledge (based on clinical experience and the empirical literature) that the disorders can be managed more effectively using the techniques being taught. Supporting self-efficacy

Resistance in therapy can often follow a setback. At such times self-efficacy decreases as the person feels that successful mastery of the problem is no longer an achievable goal. In working with a client, it is particularly important to reverse decreases in self-efficacy. Low self-efficacy appears to be a predictor of the development of fearful avoidance, the exacerbation of depression, and substance use. Therefore, if self-efficacy fails to increase, or even decreases during therapy, it is highly probable that the problem behaviours will return and therapeutic progress will be hindered.


Managing resistance by enhancing motivation

Central to supporting self-efficacy is conveying the principle that change is possible. This has already been alluded to in the context of rolling with resistance but it is important that the belief that change is possible be conveyed throughout therapy. In addition, there are three critical times when the likelihood of change needs to be explicitly communicated. First, at the start of therapy it is essential to communicate a positive and realistic expectation of therapeutic change. For example, in our group programme for agoraphobia it is common to begin with a comment such as: We have seen how fearful avoidance is driven by panic attacks and we have discussed how life would be different if you could be free from panic attacks. We know from past groups that around nine in ten people, just like you, become free from panic attacks. Free from panics not only in the short term, but we have followed these people for up to two years after treatment and they remain panic free. Although you may find this difficult to believe, our results are no different from other similar centres around the world. However, I suspect that even though I have told you that people can learn to master panics you are thinking, ‘‘I bet I’m the one in ten who doesn’t get better’’. Therefore, the more important question is not how many people are panic free, but how do you move from being the one in ten, to being one of the nine in ten? The simple answer is, you will need to work hard. The techniques that we will teach you are effective and this is demonstrated by the high success rates. Our experience has shown us that those people who do not improve (i) do not put in the effort necessary to learn the techniques, (ii) do not practice the techniques, or (iii) give up and go back to using the strategies which they have used before to partially manage anxiety and panics. We will teach you new techniques which will enable you to control your panics. It is up to you to learn and practice the techniques, working hard to conquer the panics, because when you do, you can be free of panic.

The second time when self-efficacy must be supported is during setbacks. At these times, when the client is demoralized and possibly resistant to therapeutic interventions, it is necessary to solve any problems while conveying the belief that change is still possible. The third time when self-efficacy must be particularly supported is at the termination of treatment. At these times clients are often worried how they will fare without the support of the psychologist, and if treatment has been in a group context, without the support and encouragement of other group members. This difficulty can be tackled by reminding clients that the gains during treatment were due to their efforts. In addition, it can be helpful to offer follow-up sessions. Clients are invited to attend follow-ups if they suffer setbacks or need some extra encouragement. Clients often say that they feel comfortable knowing that there is a safety net should they need one, and they feel that they can use the resource on an irregular basis.


Managing treatment non-compliance

In summary, low self-efficacy is related to failure to progress in many problems. Therefore, it is helpful to foster and support a belief in the possibility of change. Then the psychologist can provide the effective treatment techniques which make long-lasting and self-initiated change possible. Summary

Ambivalence about treatment is common among clients. There are both gains and losses associated with recovery and it is the psychologist’s role to ensure that the former always outweigh the latter. It is possible to achieve this goal by expressing an empathic understanding for the client’s condition and experience while developing a discrepancy between current functioning and the desired functioning. Conflict or resistance in therapy is best handled by avoiding argumentation (and subsequent polarization) as the psychologist rolls with the resistance, seeking to solve any problems and restore motivation, rather than pushing the client towards recovery. Implicit in all of this is that the psychologist must keep uppermost in mind the knowledge that the treatment techniques are effective and that change for the better is within the person’s capability. Conveying the attitude that change is possible will not in and of itself cure the client’s problems, but it will bring the person to the point where effective change is possible.

Managing homework non-compliance In addition to the broader issues of motivation, there is a specific behaviour in therapy that hinders progress; namely the lack of compliance with homework assignments (Shelton & Lavy, 1979, 1981a, b). This is not an insignificant problem because homework assignments play an important role in outcome (Burns & Auerbach, 1992), such that clients who are less reliable in completion of these exercises demonstrate worse outcomes (Kazantzis et al., 2000). For instance, Kazantzis and colleagues in their meta-analysis found that setting homework accounted for 13% of the variance in outcomes (r ¼ 0.36) and homework compliance accounted for 5% (r ¼ 0.22) in therapeutic outcomes. The size of these effect sizes can be used to support a number of points. First, it is important and worthwhile to encourage clients to conduct homework assignments, especially given that this is a factor that is potentially under therapist control to some degree (Bryant et al., 1999). Second, it is worthwhile reflecting upon the amount of time that should be allocated to homework, given that these activities only predict a relatively modest amount of variance in outcomes. If you find yourself struggling in vain to encourage a non-compliant


Managing homework non-compliance

client to complete homework assignments, there is still a substantial portion of the variance in therapeutic outcome to be explained by other factors. Therefore, if compliance with homework is becoming contentious, it is better to build upon the client’s strengths and focus more on those aspects of treatment that the client does engage with. However, most of the time, homework is an important component of therapy and there are a number of non-confrontational ways to increase compliance. In addressing the problems of non-compliance with homework instructions, Birchler (1988) has produced a number of recommendations. First, only provide homework assignments once a satisfactory level of rapport has been established. The rationale behind this is that the more your client values you and your opinions, the more likely they are to comply with your requests (see also Linehan, 1993a). Second, any homework that is prescribed should correspond to the therapeutic goals. Accordingly, the psychologist needs to create an expectation that completing homework will alleviate presenting problems. Third, the client should be involved in planning the homework. By maximizing the perception of control and willing participation, the likelihood of compliance will increase. Fourth, check that the assignment does not exceed the client’s present motivational levels. In this regard, consider factors such as time, energy and cost. Fifth, ensure that the task does not exceed the client’s level of competence. One way to achieve this is to observe the client practicing within the therapeutic session. Sixth, reduce any threatening or anxiety-provoking aspects of homework. The aim is to achieve goals by using small attainable steps. Seventh, make sure that tasks are specific and clear. Asking a client to repeat or to paraphrase instructions can assist this process. Giving written assignments and reminder notes can also help. Further, Birchler (1988) suggests that the psychologist considers any possible secondary gain if the client does not comply. Think about the impact of the assignment on the client’s family system and any supportive or sabotaging effects that others may have. If any can be anticipated, identify the potential problems and setbacks, and normalize these experiences. Finally, review all homework assignments. During the review the therapist should provide support for the client, help to shape early attempts into correct behaviour, and to acknowledge positive efforts. It is easy to extinguish homework compliance through non-attention. Thus, when giving homework it is important to allocate time to the process. Typically novice therapists will underestimate the time taken and will try to cram it into the last few minutes of a session. If you consider that the prescription of homework assignments will involve (i) explaining why you are asking the client to do the homework, (ii) getting the client’s involvement and commitment, (iii) describing the homework in details, (iv) requesting that the client


Managing treatment non-compliance

paraphrase and then practice the exercise it is apparent that a reasonable amount of time will need to be allocated to the exercise (especially initially). Our experience suggests that 10 minutes will not underestimate the time required to assign homework, although the time reduces as therapy progresses and the client is more familiar with the process. In addition, homework must be essential to therapy. If the assessment or the task is not essential and linked to specific therapeutic goals, then why are you wasting the client’s time with it? If the homework is essential, then it follows that you must review the homework exercise at the next session. In addition, if the homework is essential to the progress of the next session, then it is problematic if the client does not comply. Some have even suggested that if homework is not completed, consider cutting the session short and postponing the sections of the sessions that required the homework until the following week. The strength of this approach is that if we are convinced that homework is a central component to the satisfactory completion of treatment, then cutting the session short will convey clearly the value of homework to the client, and this may increase compliance. But note, while this is a direct and firm attempt by the therapist to encourage compliance with homework assignments, it avoids argumentation and rolls with resistance by adapting the course of scheduled session times without abandoning the objective to get the client to engage in treatment. Engaging the client with a therapy that stands the best chance of success is an important clinical activity. During the course of ensuring compliance, it is not unexpected that client-related factors may become of importance and these will require sensitive handling on the part of the therapist. It is to some of these issues that we will now shift our discussion.


Respecting the humanity of clients: cross-cultural and ethical aspects of practice

Individuals are functioning within a complex array of familial, social, historical, political, cultural and economic influences. Consideration of these influences draws attention to individual-specific matters such as cultural and ethical issues, as well as those that pertain to the broader social systems and structures within which both our clients and we are located. Clinical psychologists must deal sensitively with these issues in a manner that respects each client’s uniqueness and humanity while being mindful of the socio-cultural context. From Figure 11.1 it is apparent that there are a variety of ways that social, cultural and legal issues may influence the relationship between the psychologist and the client. Running through all these facets is a central theme, in which the psychologist seeks to afford the client the dignity that is warranted by virtue of being a member of the human race. Recognizing our humanity requires acknowledging our individuality as well as our corporate nature. We are individuals who live in social structures and as such we both act upon and are acted upon by our environments. This means that clients will present for therapy as unique individuals, who have been shaped by particular social, cultural, historical and political forces. The clinical psychologist needs to understand and respect how these forces can both constrain and enrich the therapeutic relationship. Like their clients, psychologists will be influenced by their own social, cultural, historical and political contexts, and they must strive to minimize any negative or constraining impact that may have on the client. If the broader social context of the practice of clinical psychology is not considered, then unforeseen problems may arise. For example, MacIntyre (2001; MacIntyre & Petticrew, 2000) has drawn attention to circumstances where the provision of a well-meaning health intervention may exacerbate health inequalities because a socio-economically advantaged person’s greater resources may offer that person greater access to the health intervention. Some of these resources will be financial, but other less obvious ones may include education, coping skills, as well as the chance or ability to take up the health opportunities.


Respecting the humanity of clients: cross-cultural and ethical aspects of practice

Figure 11.1. Influence of social, legal, and cultural factors on the practice of clinical psychology

Thus, an intervention can have the greatest effect among those who need it least. For instance, Schou and Wight (1994) examined the effectiveness of a dental health campaign in Scotland. They found that mothers of caries-free children were better educated, had better awareness of the campaign, and engaged in better dental hygiene than mothers of children with caries. This is not to say that the campaign overall was not a success, but that the intervention was differentially successful depending upon socio-economic factors. Similarly, in our own work one of us was examining the extent to which exercise was being taken up by people with intellectual disabilities living in group homes. In general, the picture was positive, but the degree of activity was strongly correlated with independent ratings of ability, such that the more active lifestyles were more common among those with the higher ability levels. Now while it is predictable that individuals with greater abilities will be more likely to hear and respond to messages about increasing physical activity, in an ideal world, a health intervention would be uncorrelated with ability. The practical implication is that clinical psychologists need to carefully consider each client as an individual and examine all the factors that may impinge upon a particular intervention.


Culture-sensitive practice of clinical psychology

In the remainder of this chapter, we will examine first some of the challenges and parameters associated with conducting clinical practice in a culturally sensitive manner. Then we will present a structured problem-solving approach that can be applied when relating to clients as unique individuals while bearing in mind cultural as well as ethical issues that may arise within the therapeutic relationship.

Culture-sensitive practice of clinical psychology Acknowledging that each client is a human being entails a recognition that each person must be treated with the dignity that they deserve. This will involve appreciating the unique qualities of each person and the cultural influences that shape them (Kazarian & Evans, 1998). Before we review some principles of culture-sensitive practice, it is necessary to consider several caveats. First, a focus on culture as a specific topic in clinical psychology could unintentionally lead to the neglect of other important qualities of an individual when planning treatment (such as their socioeconomic status, social class, gender, sexual orientation and so forth). These attributes will vary in their perceived importance among individuals and will vary according to the social context in which they live. For example, sexual orientation may be seen relatively unimportant to a middle-aged heterosexual client living a white middle-class suburban lifestyle, but a young gay man living in the same suburb, who has been socially ostracized during his schooling, may perceive his sexual orientation to be a core attribute of his self-definition. Second, the focus on large cultural differences (e.g., White American versus Black American versus Hispanic American) may overshadow important but less obvious differences. For instance, two Christian clients may present for treatment with obsessional guilt about their sinful thoughts, but if one is Roman Catholic and the other is Lutheran, the theological framework within which they would conceptualize guilt and forgiveness are fundamentally different. Third, the literature on cultural psychology itself suffers from a cultural bias, with the vast majority of it being based in North America and Europe. For instance, in a recent edited book on cultural clinical psychology only one author was working at a university outside North America. This is unfortunate since there is a risk that the literature itself will reflect a particular cultural emphasis. As residents of Australia we notice this because rarely is there any mention of the indigenous peoples of Australia and New Zealand, and there is less coverage of people likely to migrate to Australia. Although relevant research is accessible, the difficulty for the individual clinical psychologist is that there is still an insufficient empirical base for guidelines that cover each of the myriad cultural


Respecting the humanity of clients: cross-cultural and ethical aspects of practice

groups and subgroups whose members may present for treatment. For these reasons, we advocate a structured problem-solving approach to organize a culturally-sensitive understanding of each individual client. That is, the application of the culturally relevant knowledge will be so varied that it is more helpful to focus on broad principles of application rather than the specifics of each culture. In so doing, it is important to acknowledge that mainstream clinical psychology tends to reflect Western values, such as individualism. The treatments outlined in Chapter 5 all emphasize the individual as the central organizing feature. Thus, the treatments tend to give implicit assent to values such as self-reliance, self-determination, self-understanding, self-awareness and self-initiated action (Toukmanian & Brouwers, 1998). These attributes contrast with values of family kinship and community membership, and a sense of self embedded within the needs and norms of a particular group, that are emphasized in many non-Western cultures. In order to develop a problem-focused approach to address these biases, it is first necessary to appreciate the ways that cultures differ. Parameters of culture-sensitive practice

Kluckhohn and Stodtbeck (1961) identify a variety of parameters of relevance when considering the values implicit and explicit in different cultures. The first parameter is the orientation to human nature, which describes the ways that different cultures may view the nature of persons. People may differ with respect to the views about human character; whether humans are considered to be basically good, bad, neutral, or a mixture of both. They may vary in terms of what is considered to be innate to the human character, how character is produced, and what makes a human a person. A second parameter is relational orientation, which can be lineal, collateral or individualistic. That is, a key issue for any individual is how to relate to others and one’s culture provides guidelines for doing so. Within a lineal culture a person relates to others on the basis on their lineage. People may be of a higher or lower social standing dependent upon their lineage into which they are born and therefore relationships are vertical in that they extend vertically through time. Another way to address the issue of relationships with others is collateral, where society is divided into us, who may be trusted and collaborated with, and them, who are not to be trusted. In contrast to a lineal and collateral group orientation is an individualistic approach to others, in which others in society are dealt with in a manner determined by their perceived individual merit. Relationships are horizontal in that one’s lineage through time or group membership is much less relevant. Society in the USA tends to be individualistic, whereas some Middle Eastern countries are lineal and collateral. The next parameter is the relationship between people and the


Culture-sensitive practice of clinical psychology

natural world, such that people are in subjugation to nature, are in harmony with nature, or seek to master nature. Is life determined by external forces beyond personal control? Within this category we can also include the perceived relations between the person and their internal (emotional) environment. Thus, cultures may vary in terms of value placed on mastery of emotions. The fourth orientation refers to preferred mode of activity, and the orientation can be one of being, being-in-becoming and doing. This orientation will express itself in terms of the degree to which life is valued in itself, the extent to which development of the inner self is valued, and the extent to which rewards in life are seen to be self-determined and obtained through individual effort. Cultures may also vary in terms of the relationships between people. Individuals in different cultures may differ with respect to the extent to which they believe in individual autonomy, independence and competition versus leadership, helping, cooperation and interdependence. These perceptions will also influence the way that friends and families may be perceived, such that some cultures may view friends and family as the primary means of problem solving, whereas other cultures may emphasize autonomy and independence in problem-solving. Finally, there is an orientation to time, where the focus can be on the past, present or the future. Cultures within which people tend to focus on the past may emphasize tradition and focus on history, whereas people from present-focused cultures emphasize living for today, and people from cultures with a future focus will be more inclined to live in a way that sacrifices are made with the aim of creating a better future. For example, Western culture tends to view human nature in a negative or neutral manner, possess an individualistic focus, perceive the need to exercise mastery over nature, evaluate individual worth in terms of what one can do, and emphasize the future more than the past or present. Awareness of the parameters of cultural differences allows clinical psychologists to articulate their own beliefs, values and attitudes so that they can recognize differences and respond appropriately. Conducting a self-evaluation will assist a psychologist to be aware of the extent to which they are able to accept differences and the need to learn about other cultures. Learning about other cultures involves deliberately taking opportunities to expose one’s self to other social groups, cultures and sub-cultures. This may include partaking in cultural events and activities, as well as seeking insights through media such as books and film. With the benefits of a self-evaluation regarding the relevant cultural parameters, the psychologist will be in a better position to assess if any of these parameters are relevant to the treatment of a particular client. Most often this assessment will need to be made by the therapist, because values tend to be implicit and therefore clients may not be able to articulate key issues. The aim is


Respecting the humanity of clients: cross-cultural and ethical aspects of practice

to evaluate the extent to which the attributes of the individual affect the therapeutic communication and process of treatment. In so doing, ensure that as a clinician both your verbal and non-verbal messages are congruent and culturally appropriate. For instance, Eastern cultures tend to be more reserved than Western cultures and therefore it can be inappropriate to engage with the client in an open and frank discussion about problems related to themselves and their family in ways that might be appropriate with a client from a Western background. In terms of the therapeutic process, it is important to consider that the therapeutic goals are culturally consistent or that the method of intervention is including the relevant individuals. For example, certain behavioural changes may meet with the approval and support of key family members while other changes may bring about cultural disapproval or sanctions. O’Leary et al. (1986) found that training women in assertiveness was associated with increases in domestic violence; therefore a clinician needs to be mindful of the social and cultural context within which a person resides. When a few possible courses of action or methods of proceeding are enumerated, the clinician can specify the possible consequences, both positive and negative, to the different options. Once articulated, a decision can be made, implemented and evaluated. If the evaluation indicates a negative outcome, then an alternative action plan is initiated. Thus, the process once more is akin to structured problem-solving in that the stages are define problem, develop alternative courses of action, evaluate and then choose an action, and evaluate the outcomes. We will now turn to a consideration of structured problem solving as a clinical technique and its application to the practice of culture-sensitive clinical psychology.

Applying structured problem-solving to culture-sensitive practice Structured problem-solving was developed by D’Zurilla (1986) and it can assist clients identifying problems, recognize resources they possess, and teach a systematic method of overcoming and preventing problems. Structured problem-solving recommends moving through a sequence of steps (see Hawton & Kirk, 1989). The first step is to define the current problem. If there are multiple problems, these can be dealt with sequentially after an order for dealing with them has been chosen. The second step it to brainstorm all the possible solutions. Once a list of possible solutions is written down, then the therapist and client can evaluate the pros and cons of each and in so doing select what they think will be the best solution. This option is then implemented; a step that will involve preparing a plan of action in which the necessary steps are clearly articulated and then


Applying structured problem-solving to culture-sensitive practice Table 11.1. Analogies between structured problem solving, the process of research and the conduct of clinical practice.

Problem solving



Problem definition Brainstorming Choose solution Implement solution Evaluation

Research question Hypothesis generation Select hypothesis Conduct study Analysis/interpretation

Presenting problem Preliminary formulations Chose intervention Implement treatment Evaluation

enacting that plan. Sometimes cognitive or behavioural rehearsal (e.g., role plays) can be useful in preparing the client, for anticipating difficulties, and building a sense of self-efficacy among clients. Finally, the implemented solution is evaluated, by asking if the solution did indeed solve the problem, by assessing the success and failure against some pre-agreed criteria. If it failed to redress the difficulty, the clinical psychologist and client can select the next best solution, brainstorm some other solutions, or even check that the problem has been correctly identified and fully articulated. Table 11.1. outlines these five stages of problem solving, by drawing parallels with two activities familiar to psychologists. The central column identifies a series of stages in the process of conducting research. Research begins with identification and selection of the research question, which in turn will lead to hypothesis generation. Of the possible hypotheses, the research will select a subset. These steps of research are analogous to problem definition, brainstorming and selecting a solution. A researcher then conducts a study to test between hypotheses and analyses the data to determine the fate of the hypothesis, which is analogous to implementing and evaluating a possible solution to a problem. Thus, the structured problem solving approach is one that is familiar to a psychologist trained in research. Furthermore, the parallels also extend to the model of clinical practice we have been outlining. The clinician identifies a presenting problem, generates a formulation, which in turn will guide the choice of an intervention. After implementing the intervention, the clinical psychologist will measure the effectiveness of the treatment by conducting an evaluation. This same approach can be extended to situations where cross-cultural matters need to be considered and responded to. The strength of the approach is that while it is possible to take into account some general principles or theories about culture, each situation is unique and will require a considered individual solution. For example, Lo´pez (1997) describes a couple who migrated to the


Respecting the humanity of clients: cross-cultural and ethical aspects of practice

USA from North Mexico. They presented with marital difficulties which had reached a point at which the couple have settled into a pattern of silence interspersed with verbal hostility. Initially, the husband only agreed to attend treatment separately from his wife. Therapy was soon abandoned when he indicated that his wife was to blame for their problems. He believed that he fulfilled his role as a husband (by working hard and providing financially), but that she failed to fulfil her role as a wife (by failing to cook meals, wash clothes, and be available for sexual relations). Later they attended as a couple but one problem arose when the therapist offered the interpretation that perhaps the husband felt hurt that his needs were not being considered by his wife. He responded that no-one could hurt him, but that if they did then he would make sure that they knew it. He indicated that he was a strong man and that the efforts on behalf of his wife and daughters to make him a wimp would fail. The case study highlights a number of problems which could be addressed by taking a problem-solving perspective. In reflecting on the case, Lo´pez notes that his suggestion was problematic in that it elicited a vehement response from the client that did not facilitate change. Thus, the therapist could reconsider the way this suggestion was offered by re-evaluating the impact of the cultural context from which the couple came, issues that may have arisen concerning acculturation to life in the USA, possible discrepancies between the husband and wife’s views of the problem and the person responsible of change, and perceptions of the purpose of therapy. In so doing, the problem-solving provides a framework for addressing potentially difficult cultural issues in therapy. The same holds true when considering how ethical principles (such as those articulated in the codes of ethics developed by each country’s psychological society) apply to a particular situation or therapeutic relationship.

Applying structured problem-solving to ethical decision-making Consider a client who seeks counselling after receiving a positive HIV test result. He is unsure how he became infected but thinks that it followed a homosexual encounter while he was exploring his sexuality. A typical session would involve outlining his prognosis as well as describing safe sex and what he could do to protect sexual partners from infection. Consider how you would respond if the client informed you that he was soon to marry his fiance´e and settle down. He did not want to inform her that he was HIV positive in case it affected his marriage plans. A practical way to handle ethical situations such as the one just described builds upon a structured problem-solving approach (see Keith-Spiegel &


Applying structured problem-solving to ethical decision-making

Koocher, 1985 and Eberlein, 1987). It identifies ethical dilemmas as problems that require solutions and rather than prescribing answers, it provides a problem-solving framework within which to seek a set of possible solutions. Keith-Spiegel and Koocher (1985) suggest that the place to begin is by describing the parameters of the situation. In the preceding example, these would involve his HIV infection and the relationship with his fiance´e. The second step is to expand on the problem by identifying the key ethical issues. Redlich & Pope (1980) suggested the following principles to guide ethical decision-making. They noted that psychologists should (i) do no harm, (ii) practice only within competence, (iii) do not exploit, (iv) treat people with respect for their dignity as humans, (v) protect confidentiality, (vi) act (except in extreme cases) only after obtaining informed consent, and (vii) practice (as far as possible) within the framework of social equity and justice. These principles highlight the need to protect the client’s confidentiality, but also to take into account the need to avoid harm to the client’s fiance´e. However, what is a needed is an organizing framework to decide when there are conflicts among principles. The Canadian Code of Ethics for Psychologists (Canadian Psychological Association, 2000) has isolated a set of principles and organized them into a hierarchy to assist ethical decision-making. The hierarchical organization implies that the principles are considered in order and greater weight is given to those higher in the hierarchy. The first principle is respect for the dignity of persons. Except when a person’s physical safety is under threat, assuring people’s dignity should be the most important ethical principle. Responsible caring is the second principle and implies the caring should be carried out competently while respecting dignity. The third principle is integrity in relationships. They note that on occasions the values of openness and straightforwardness might need to be subordinated in order to maintain the respect for human dignity and responsible caring. Finally, they highlight the responsibility to society and suggest that this principle be given the lowest weight when they are in conflict. They suggest that ‘‘When a person’s welfare appears to conflict with benefits to society, it is often possible to find ways of working for the benefit of society that do not violate respect and responsible caring for the person. However, if this is not possible, the dignity and well-being of a person should not be sacrificed to a vision of the greater good of society, and greater weight must be given to respect and responsible caring for the person’’ (CPA, 2000, p. 4). As an aside, the reader will notice that this last point makes explicit a cultural position on the parameter of the relationships between people in which individual autonomy is valued over interdependence and therefore it will be necessary to be sensitive to the cultural sensitivities of clients who may not hold this view. However, when considering


Respecting the humanity of clients: cross-cultural and ethical aspects of practice

the preceding example, it would be clear that the possible specific threat to another person may take ethical precedence. The next step is to consult any available professional guidelines to see if these might assist in the resolution of each issue. Most professional guidelines for psychologists share a similar structure. There are guidelines relating to professional practice, the conduct of research, issues that are specific to working with human or animals, and regulations relating to the professional society. The ethical guidelines cover matters related to general professional conduct, maintaining and working with professional competence, obtaining consent, and confidentiality. Considering the preceding example, the British Psychological Society’s ‘‘Code of conduct, ethical principles and guidelines’’ notes that ‘‘in exceptional circumstances, where there is sufficient evidence to raise serious concern about the safety or interests of recipients of services, or about others who may be threatened by the recipient’s behaviour, take such steps as are judged necessary to inform appropriate third parties without prior consent after first consulting an experienced and disinterested colleague, unless the delay caused by seeking this advice would involve a significant risk to life or health’’ (British Psychological Society, 2005, pp. 34). Similarly, the Canadian Psychological Society (2000) recommends to ‘‘Do everything reasonably possible to stop or offset the consequences of actions by others when these actions are likely to cause serious physical harm or death. This may include reporting to appropriate authorities (e.g., the police), an intended victim, or a family member or other support person who can intervene, and would be done even when a confidential relationship is involved’’ (p. 22). Thus, professional guidelines provide some direction about how to proceed. With this information, Keith-Spiegel and Koocher (1985) suggest that the next step is to evaluate the rights, responsibility and welfare of affected parties. In the present example these issues relate to the client’s right to privacy and the fiance´e’s right to safety and protection. After describing these rights, the next step is to generate the alternative decisions possible for each issue and enumerate the consequences of making each decision, considering any evidence that the various consequences or benefits resulting from each decision will actually occur. When this has been done it will be possible to make a decision and evaluate its success, which in the current example would identify the need to inform the fiance´e. After having made a decision, the best way to implement the chosen course of action will need to be determined. For example, the clinician could boldly inform the client that regardless of his wishes the therapist was going to contact his fiance´e or, alternatively, could decide to spend time in therapy considering the consequences for the client and fiance´e of his proposed course of action. The hope of the latter discussion would be to bring the client to a realization of


Applying structured problem-solving to ethical decision-making Table 11.2. Worksheet for assessing ethical dilemmas.

Worksheet for Assessing Ethical Dilemmas Describe the parameters of the situation __________________________________________________________________________ __________________________________________________________________________ Define the potential issues involved __________________________________________________________________________ __________________________________________________________________________ Consult guidelines, if any, already available that might apply to the resolution of each issue __________________________________________________________________________ __________________________________________________________________________ Evaluate the rights, responsibility and welfare of affected parties __________________________________________________________________________ __________________________________________________________________________ Generate the alternative decisions possible for each issue __________________________________________________________________________ __________________________________________________________________________ Enumerate the consequences of making each decision __________________________________________________________________________ __________________________________________________________________________ Present evidence that various consequences or benefits resulting from each decision will occur ___________________________________________________________________________ ___________________________________________________________________________ Make your decision and evaluate the outcome __________________________________________________________________________ __________________________________________________________________________

his responsibilities as a fiance´e and a fellow human and the possible outcomes of different actions. The principle of respecting the client’s confidentiality and individual dignity must be weighted against the risk of delaying disclosure to the fiance´e, who would remain at risk of being seriously harmed if the therapist chooses to not inform the fiance´e immediately. Thus, ethical decision-making is like structured problem-solving in that the stages are define problem, develop alternative course of action, analyze courses,


Respecting the humanity of clients: cross-cultural and ethical aspects of practice

choose action and evaluate. This process is depicted in Table 11.2. You may find it helpful to use this worksheet as you consider how the model would apply to situations you might encounter in your training. Confidentiality

Having described a general problem solving strategy for addressing ethical issues, it is relevant to consider some specific ethical issues. Confidentiality is an issue that arose in the context of discussing case management. To reiterate, the term acknowledges that when a client enters therapy they inevitably relinquish a degree of personal privacy, by providing the therapist access to normally private information. However, the client has the reasonable expectation that any information disclosed to the therapist remains confidential. Thus, confidentiality refers to legal rules and ethical standards that protect clients from the unauthorized disclosure of information that has been disclosed in therapy or has arisen in the course of therapy. Ethical guidelines require clinical psychologists to maintain client confidentiality and in so doing reflect the principle that confidentiality is the prerogative of a client not a therapist. That is, a client can choose to take a therapist into their confidence by providing that information, but the client still retains control of that information. The client may permit the therapist to communicate the confidential material to a third party (e.g., give writer permission to include the material in a referral letter to another mental health professional), but the decision in almost all circumstances lies with the client. Dual relationships

Having described a general problem-solving strategy for addressing cultural as well as ethical issues in respecting the humanity and dignity of individual clients, one aspect is worthy of specific attention. This concerns dual relationships. A dual relationship exists when a therapist is in another, different relationship with a client. Usually this second relationship is social, financial or professional. For instance, if a professor of clinical psychology required students to enter into psychotherapy with him or herself as part of their training in clinical psychology a dual relationship would exist. In such an instance, the psychotherapeutic relationship co-exists with an educational relationship where the professor grades the student’s work. These other relationships have the potential to erode and distort the professional nature of the therapeutic relationship, create a conflict of interest, as well as potentially compromise the professional disinterest and sound judgement required for good practice. On the other hand, the existence of a therapeutic relationship means that a client or ex-client cannot enter into a business or secondary relationship with the therapist on an equal


Applying structured problem-solving to ethical decision-making

footing because there is the potential for a therapist to use confidential information maliciously. In addition, if a therapist is invited or compelled to offer testimony regarding some aspect of therapy, the existence of a dual relationship will undermine credibility as a witness. Thus, as a general rule, it is best for psychologists to avoid dual relationships with clients altogether. One particular form of dual relationship that therapists need to be on their guard about is sexual relationships with their clients. For instance, the Canadian Psychological Association (2000) warns ‘‘Be acutely aware of the power relationship in therapy and, therefore, not encourage or engage in sexual intimacy with therapy clients, neither during therapy, nor for that period of time following therapy during which the power relationship reasonably could be expected to influence the client’s personal decision making’’ (p. 21). If trainees find themselves in a situation where sexual tension or innuendo appears to be present during sessions with a client, the onus is on the trainee to immediately consult with a supervisor on how to resolve the situation and ensure that interactions with the client are re-focused on the purposeful application of science-informed treatment strategies within the bounds of a caring and strictly professional relationship. Although dual relationships are to be avoided, there are some situations in which avoidance becomes increasingly difficult. One such situation is in the context of clinical practice in rural or remote settings. The luxury of restricting the relationship between the clinical psychologist and the client to a purely professional one is often not possible in small rural towns and therefore, this special case will be examined in some depth in the following chapter.


Working in rural and remote settings

Psychological practice in rural and remote settings involves several unique personal and professional challenges. Generally, very few psychology trainees are formally prepared for those challenges because curriculum components and supervised practice experiences tend to be focused on urban and metropolitan settings. Perhaps not surprisingly, historical shortages of specialty mental health professionals are a persistent problem in most rural communities (DeLeon et al., 2003). For example, in Australia, one quarter of the population lives in rural and remote areas (Harvey & Hodgson, 1995), but only about 12 percent of all Australian psychologists live and work in those areas (Griffiths & Kenardy, 1996). Mental health services in rural communities There is no consensus regarding the definitions of rural or remote as opposed to metropolitan, but a common characteristic of rural and remote communities is that they are descriptive of areas where the population density is low (U.S. Census Bureau, 2002) and geographic distance imposes restriction upon accessibility to the widest range of goods and services and opportunities for social interaction (Australian Bureau of Statistics, 2001). Long distances and harsh environmental conditions constitute significant barriers for rural residents to access mental health services (DeLeon et al., 2003). Likewise, delivering services to where they are needed by consumers can be a daunting routine if a home visit by a psychologist means driving several hundred kilometers (Lichte, 1996). If hospitalization for severely disturbed individuals is required, the logistics of transferring a client to an in-patient psychiatric unit, usually located in the nearest regional centre or city, creates considerable burden for the referring clinician as well as for clients and their families (Lichte, 1996). There also exist economic barriers to health care utilization in rural areas, because rural economies are fragile. They often depend on a single industry and are at


Maintaining professional boundaries in the rural fishbowl

the mercy of the uncontrollable whims of nature such as floods, draught, wildfires, frost and hail (Barbopoulos & Clark, 2003). As a result, financial stresses among rural residents are common and health insurance coverage may be suboptimal. In addition to these geographic and economic barriers to mental health service utilization, help-seeking behaviours are influenced by social context. Rural residents may be reluctant to seek help for psychological problems because of prevailing attitudes in rural areas to be self-reliant and to consider talking about one’s problems a luxury (Wolfenden, 1996). The diminished degree of privacy in close-knit small communities can also heighten self-consciousness about seeking help for problems that are associated with social stigma such as mental illness, drug abuse or domestic violence (Stamm et al., 2003). This high visibility and interconnectedness of individuals living in small communities is often likened to living in a fishbowl, which makes it impossible for anyone, including the local psychologist, to slip into anonymity (Dunbar, 1982). Psychology trainees who wish to gain experiences in rural settings will need to learn to cope with a number of specific personal and professional challenges that living and working in the rural fishbowl present.

Maintaining professional boundaries in the rural fishbowl The activities and associations of a small town psychologist are under regular observation. Encounters with clients in the street, supermarket, post office, swimming pool, social clubs, school function or any local event are inevitable (Dunbar, 1982). The highly visible public image of rural practitioners greatly curtails their personal privacy and affects the personal and professional lives of their families. Likewise, the opportunities for observing clients or potential clients outside the treatment context are enhanced, and the therapist may inadvertently learn more about a client from other clients since their social and professional lives are more intertwined in a small community (Hargrove, 1982). Figure 12.1 illustrates how this blurring of professional and personal roles affects the therapeutic process. The context of the rural fishbowl increases the likelihood that the client data available for inspection includes information and affective reactions linked to the clinician’s own personal and private life. This has the potential to both sharpen and blur the acuity of the expert lens through which the therapist filters client data for the purpose of case formulation. Whereas urban-based ethical guidelines hold psychologists responsible for avoiding interactions with clients outside the therapy sessions, there are at least two reasons why ‘‘rural practitioners must be careful not [italics added]


Working in rural and remote settings

Figure 12.1. Applying the scientist-practitioner approach in rural practice

to ignore or avoid their clients outside of the therapy sessions’’ (Campbell & Gordon, 2003, p. 432). First, unlike their urban counterparts, rural psychologists typically do not have other colleagues to whom they could refer clients they personally know. Thus, avoiding dual relationships could mean depriving rural clients of the only specialist mental health service available to them. Second, to be effective, psychologists must first become part of the community (DeLeon et al., 2003). Their active community involvement is essential for lessening suspicion, increasing approachability, and ultimately gaining acceptance as the local mental health expert (Schank & Skovholt, 1997). This is increasingly true if there are particular sub-cultures, racial minorities or indigenous groups living in the area or if you find yourself part of an ethnic or cultural minority. Consequently, multiple non-sexual relationships in rural practice are not only expected, they are encouraged! (Campbell & Gordon, 2003). This blurring of professional and personal roles in rural practice requires that practitioners are particularly mindful of the ethical obligation to manage multiple relationships in a way that they do not impair the objectivity and effectiveness of the therapist or expose the client to exploitation or harm (American Psychological Association,


Maintaining professional boundaries in the rural fishbowl

2002; Australian Psychological Society, 2003). The extent to which these ethical ambiguities are handled in a comfortable and competent manner may in large part determine the success of the rural practitioner (Hargrove, 1982).

Strategies for managing multiple relationships in rural practice

Because of the specific ethical demands that arise in rural settings, the standard principle of strict separation between personal and professional roles expected in urban practice cannot be applied automatically in rural practice. Several authors (Barbopoulos & Clark, 2003; Campbell & Gordon, 2003; Schank & Skovholt, 1997) sought to address this ethical dilemma by offering a number of practical guidelines for how rural practitioners can manage multiple relationships in an ethical manner: . Compartmentalize roles and relationships. This involves keeping different roles mentally separated when interacting with clients, and adopting a demeanour in line with the role relevant in a given instance. This allows the practitioner to be a professional helping expert one day, and a fellow parent at a school meeting the next. That is, in the latter situation, the practitioner can be warm and friendly while maintaining confidentiality, but will drop any air of the expert helper and will deliberately embrace a stance reflecting the situational context and purpose of the present contact. Relationships can also be separated in terms of degree of involvement. Shopping at a local grocery store where a client might be working constitutes less of a softening of boundaries than hiring a client (who may be the only electrician in town) to do some work in one’s home. In the urban environment, boundaries usually are protected by the cloak of anonymity; in the rural setting, compartmentalizing private and professional roles means learning to wear the right hat for the right occasion. . Document overlapping relationships in case notes. An important strategy to avoid the risk of boundary violations or the accidental disclosure of confidential information is to make explicit in the documentation of case progress the nature and details of overlapping relationships. This will help clinicians to keep original sources of information clear in their mind and minimize the risk of unintentional breaches of confidentiality. . Discuss out-of-therapy contact with clients upfront. It is good practice to routinely discuss with clients at the start of treatment the high likelihood of out-of-therapy contact. Clients can be assured that every effort is made to respect their privacy during chance encounters and contacts that may even be predictable in a small community. Clients are given the opportunity to communicate how they feel about such encounters, how they intend to respond and how they wish the therapist to respond.


Working in rural and remote settings

. Obtain informed consent. As with explicit documentation of overlapping







relationships in case notes, informed consent forms should include explicit mention of any multiple relationships and state that the client has been made aware of this issue when consenting to engage in treatment. Educate clients about professional boundaries. Clients should not be assumed to know what therapists mean by professional boundaries. It may be necessary to explain to some clients what a professional boundary is. This may take the following form: ‘‘Because you are my client, you cannot be my friend. I listen to you, I care about you  but friends care about one another. But you don’t come in so that I can sit down and tell you about my problems and my life. I don’t call you when I am hurting or need a friend for support’’ (adapted from Schank & Skovholt, 1997, p. 47) Stick to time limits. Beginning and ending therapeutic contacts strictly within the designated appointment times helps to highlight the professional nature of the relationship. Develop procedures that reduce accidental disclosures. The exchange of information between professionals in a small community may require additional safeguards to protect client confidentiality. For example, files or reports sent to a physician in a hospital might be open to inspection by administrative or other staff who know the client or members of the client’s family. Monitor one’s own comfort level. If therapists experience discomfort with a dual relationship, that can compromise their objectivity and effectiveness. For example, a therapist might learn that her daughter is bringing a friend home after school who also happens to be a client of the therapist. The therapist has to weigh competing ethical choices: protect the client’s confidentiality and cope with the personal discomfort, or break confidentiality by restricting whom her daughter can have as friends. Which choice is in the best interest of the client depends on the therapist’s ability to compartmentalize the relationships and manage her level of discomfort while remaining therapeutically effective. Put client’s needs first. Therapists need to reflect about their motives for maintaining dual relationships, so that clients are not used inadvertently for one’s own gratification or exploitive purposes. Imagine the worst case scenario. In deciding whether or not it is in the client’s best interest to maintain a dual relationship, it can be very instructive to consider the possible harm that could stem from the relationship not only in the present but also in the future.


Coping with professional isolation

. Monitor the slippery slope phenomenon. Boundary compromises that seem

minor in isolation can have cumulative effects and lead to more substantial boundary violations. . Monitor warning signs of role-boundary conflicts. It is essential to be aware of any changes in the nature of interactions in overlapping relationships. Is there more self-disclosure by the therapist? Is there greater anticipation of meeting with a client? Does the therapist feel a desire to prolong a session with a client or increase the frequency of meetings with the client? Is the therapist reluctant to terminate or refer a client? Does the therapist want to please or impress a client? Affirmative answers to these questions indicated an increased potential for role-boundary conflicts in multiple relationships. . Terminate overlapping relationships as soon as possible. Prompt termination of multiple relationships following the conclusion of their primary purpose is in the client’s best interest. . Seek consultation. Because of the professional isolation of rural psychologists which limits the opportunities for ad hoc consultation with colleagues regarding ethical issues, the onus is on the psychologist to make special efforts (e.g., using telecommunication or internet tools) to maintain links with other professionals who can provide feedback on ethical decisionmaking.

Coping with professional isolation Ethical decision-making is not the only aspect of rural practice affected by professional isolation. As shown in Figure 12.1, the rural psychologists must deliver the core clinical tasks of applying science-informed, up-to-date knowledge and skills to case formulation and treatment planning, often without easy access to consultation from other mental health experts, state-of-the-art diagnostic and treatment resources, or continuing education (Stamm et al., 2003). It is therefore essential that rural practitioners learn to practice independently with minimal support from colleagues within their own discipline, and be comfortable with assuming ultimate responsibility for decisions concerning case management (Lichte, 1996). On some occasions this might mean working under conditions well beyond what they were prepared to do (Gibb et al., 2003). As a backup, rural practitioners must become familiar with what clinical services are available in the nearest metropolitan area and develop procedures for facilitating long distance referrals (Keller &


Working in rural and remote settings

Prutsman, 1982). Although working in relative isolation is demanding and can lead to professional burnout, there are also positive features associated with isolation, including a greater sense of autonomy and opportunities to respond to community circumstances with a great deal of flexibility and creativity (Wolfenden, 1996). Telehealth

The advent of sophisticated telecommunication technology is increasingly providing rural practitioners with alternative means to overcome some of the barriers associated with professional isolation. Figure 12.1 indicates how the application of telehealth facilities can moderate the impact of professional isolation in the delivery of psychological services. Telehealth refers to ‘‘the use of telecommunications and information technology to provide access to health screening, assessment, diagnosis, intervention, consultation, supervision, education, and information across distance’’ (Farell & McKinnon, 2003, p. 20). Although telehealth is expected to improve the provision of care to underserved and isolated communities considerably, its potential to do so is still limited because of the digital divide between urban and rural areas (Stamm, 2003). That is, development of the technological infrastructure in many rural areas is lagging behind the rapid spread of information technology systems in metropolitan areas. Likewise, there is an urgent need for professional organizations and regulatory bodies to catch up with the digital revolution. Standards are needed to resolve legal and regulatory issues of providing care at a distance across state lines and different jurisdictions, as well as supervision for trainees without professionals licensed in their field being physically present (Stamm, 2003). Nonetheless, the use of the telephone, e-mail, Web-based applications and automated interfaces such as Interactive Voice Response (IVR) systems, are promising to ameliorate the isolation of rural mental health professionals and thereby improve direct patient care and opportunities for consultation, supervision and continuing education (Miller et al., 2003; Wood et al., 2005). Finally, telehealth can also be instrumental in moderating the impact of professional isolation by facilitating the use of informal support networks and multidisciplinary collaboration (see Figure 12.1). Incorporating natural support networks and multidisciplinary care

The relative scarcity of mental-health resources in rural regions makes coordination with medical practitioners, social services, law enforcement agencies, educational institutions, religious communities and informal support systems imperative (Stamm et al., 2003). As mentioned earlier, rural residents often feel reluctant to seek help for mental-health problems. In one recent study,


Coping with professional isolation

of those who had screened positive for depression, anxiety and alcohol abuse disorders, and who had received education about the respective disorders and available treatment services, 81 percent failed to seek help because they ‘‘felt that there was no need to’’ (Fox et al., 2001). Of those who had sought help for mental health problems in the past year, most approached a friend or family member rather than a psychologist or physician (Fox et al., 2001). By tapping into such natural support networks during treatment planning, the isolated professional can extend the reach of continuing care. Of course, before family members and friends are co-opted in any treatment plan, it is important to determine to what extent the social group is creating or exacerbating the presenting problems of the patient (Dunbar, 1982). Similarly, para-professionals and volunteers for crisis counselling and similar adjunct services can be a valuable resource, but care must be taken in selection, training and supervision of those informal helpers (Heyman & VandenBos, 1989). Traditionally, most rural psychology is practiced by professionals without expertise in advanced psychological skills, such as physicians, nurses, welfare workers, teachers or clergy (Wolfenden, 1996). Developing partnerships with those established mental health service providers in rural communities is particularly important. By collaborating with established agencies and community referral systems (see Figure 12.1), the psychological expert can engage their familiarity and credibility to contribute quality mental-health care to the community (Sears et al., 2003). Depending on available resources and local circumstances, such multidisciplinary collaboration may involve informal contacts or coordinated links between referral systems, or even integrated partnerships with sharing of resources, personnel and responsibilities for development of service delivery systems (Lewis, 2001; Sears et al., 2003). Thus, the development of consultancy skills is an essential prerequisite for psychologists in rural settings. Rural psychologists need to educate the community about the unique expertise that psychologists bring to patient care, and they need to be prepared to provide consultancy services for a broad range of community needs and problems. Rural psychologists have an important educational role. Community education involves expanding the appreciation of what psychologists have to offer, reducing the stigma and misinformation associated with mental disorders and providing information on how to achieve and maintain optimal health (Lichte, 1996; Wolfenden, 1996). In addition, rural psychologists can address the relative lack of professional development opportunities in rural settings by offering information sessions and workshops for other mental health workers (Barbopoulos & Clark, 2003). Similarly, rural psychologists can help inform


Working in rural and remote settings

laypersons and self-help groups by organizing public presentations and community events related to mental health. They should liaise with community leaders and elders, including religious institutions, to promote psychological approaches for bringing relief to people who experience personal crises and suffering. Enlisting the sponsorship of these influential members of the community helps to gain the trust of rural residents and establish the psychologist as a valuable participant in addressing local needs. Perhaps the best advertising for psychological services is first-hand experience of what the psychologist does (Wolfenden, 1996). One thing that psychologists are trained to do particularly well, and that sets them apart from most other mental-health professionals, is applying research skills to applied problems such as the design and implementation of programme evaluation studies. For example, rural practitioners can play a critical part in developing prevention and outreach programmes or crisis response teams (Barbopoulos & Clark, 2003). Most rural mental health services have few, if any, staff resources in this area. By virtue of their training as scientist-practitioners, psychologists will be called upon to contribute their expertise in selecting the appropriate techniques from the programme evaluation literature and measuring the success of target outcomes (Sears et al., 2003). This important role of the rural psychologist as a programme evaluator is illustrated in Figure 12.1 by the additional feedback loop linking the Evaluation & Accountability component of the model to Community Referral Systems. Particularly, in the present era of accountability, these evaluations may be useful in supporting efforts of a community to lobby for additional resources to support local health care services. However, the specialist knowledge and skills of the psychologist are not sufficient for being a successful rural practitioner. In light of the scarcity of mentalhealth professionals in rural settings, psychologists can achieve maximum utility with practical patient outcomes only if they are able to respond to a wide range of problems across people of all ages, types and backgrounds (Sears et al., 2003). In addition to dealing with adult psychopathology, the clinical activities include relationship and family counselling, behavioural management programmes for children or individuals with disabilities, care of rape and domestic violence victims, critical incident management, and a host of other problems. Rural psychologists may also find themselves acting as social workers, housing advocates, or liaison officers between distressed individuals and other community agencies. In other words, the effective rural psychologist above all fulfils a generalist role (see Figure 12.1). Of course, it is desirable for a generalist to have a wide repertoire of skills, but more important is that ‘‘the generalist has a method of intervention that can provide a guide and framework into most any situation’’ (Dunbar, 1982, p. 63). As we have illustrated throughout this manual,


Coping with professional isolation

and again in Figure 12.1, a scientist-practitioner approach serves as a reliable framework for adapting one’s practice to the particular professional challenges one might encounter in any situation or setting, including those presented by working in the rural fishbowl. A science-informed practitioner of clinical psychology is also well-placed to extend their professional role beyond the traditional focus on mental health into the broader domain of general health care. Thus, the final chapter will consider these newer frontiers of clinical psychology.


Psychologists as health care providers

The role of psychology in health care delivery and policy has undergone a dramatic sea change. Joseph Matarazzo’s (1980) vision of a quarter of a century ago, that ‘‘some of what is today called clinical psychology will soon be labelled health psychology’’ (p. 815), is now reality. The core identity of clinical psychologists has broadened from the traditional focus on mental health to a professional role that brings psychological expertise to the maintenance and restoration of health more generally. That is, psychologists have become health care providers, who provide specialist services along the entire continuum from enhancing psychological and physical wellness, to preventing and alleviating acute and chronic illnesses, as well as coping with death and dying (Johnson, 2003). This identity makeover was born out of decades of psychological research demonstrating unequivocally that there is more to health than biology (Anderson, 2003). The expanded role of psychology in health care is reflected in the American Psychological Association’s recent amendment to their mission statement that now includes the advancement of psychology as a means of promoting health (APA, 2005). Among the ten leading causes of illness in industrialized nations are lifestyle behaviours such as smoking, poor diet, lack of exercise, alcohol misuse, sexual behaviour, and illicit drug use (Johnson, 2003). In addition to health threats associated with these behaviours (e.g., cardiovascular diseases, cancer, HIV/ AIDS), health and illness are influenced by psychological factors such as stress, positive and negative emotional states, beliefs and coping styles, and social relationships (Salovy et al., 2000; Stowell et al., 2003). It is now well documented that psychological interventions targeting these factors can make a significant contribution to the prevention and treatment of medical conditions, as well as the promotion of healing (Nicassio et al., 2004; Schein et al., 2003). There is optimism that psychology as a discipline is well poised to move to the centre stage of health care delivery systems (Anderson, 2003). However, as much as the mere presence and severity of physical illness is an incomplete conceptualization


Psychologists compete for health care resources

of health (Johnson, 2003), the integration of non-biological dimensions of health and well-being will only flourish in this era of burgeoning health care costs if they ‘‘command enough attention as an economically [italics added] important public health outcome’’ (Smith et al., 2004, p. 128). That is, the expanded role of psychologists as health-care providers is constrained by the parameters of an evolving health-care market. Psychological interventions that do not target symptoms of psychopathology or psychological aspects of medical conditions, but aim to enrich people’s functioning or promote personal growth, fall outside these parameters and are on the patient’s nickel (Barlow, 2004). This raises the question of when psychological services are necessary health care, and when they are discretionary (Belar, 1997). The answer to this question is likely to remain a moving target (Mohl, 1998), but failing to pay for available empirically supported treatments will be costly in the long run for any health care system. Thus, necessary health care will be care that reliably improves health outcomes at a cost the market will bear, and that satisfies the consumer (i.e., the patient). The scientist-practitioner training, with its emphasis on science-informed practice, outcome evaluation and ongoing quality improvement in service delivery, provides precisely the skills needed for clinical psychologists to add value to traditional medical approaches in a competitive health care market. However, for clinical psychologists to become established as health care providers on a par with medical professionals, they need to make adjustments to their traditional modes of delivering psychological treatments. This includes an understanding of the health care market place, a focus on good enough treatment, an investment in consumer education and marketing of services, and a willingness to embrace the culture and pace of integrated care settings (Kiesler, 2000).

Psychologists compete for health care resources The continuing evolution of current health care systems and practices is driven by two major forces: the primacy of evidence-based treatments (i.e., accountability), and the imperative of cost-effective delivery of care. To be competitive in the health care marketplace, providers  including psychologists  need to offer empirically supported services at the lowest possible cost (Tovian, 2004). In the traditional fee-for-service model, practitioners tended to treat patients over an extended period of time, without requirements to account for outcome or length of treatment (Sanchez & Turner, 2003). In such a system, there is no incentive for cost-effective treatment, because the more services are offered the higher the income for the provider. The resulting escalation of mental health care costs led


Psychologists as health care providers

to the emergence of various managed care systems. Although these systems vary considerably in the type of cost-control strategies used (e.g., limit number of sessions, reduce fees for services, manage mental health costs separately from general medical costs), and in the extent to which they have private or public sector involvement, they all involve some kind of capitation. That is, the demand for services by a specific number of patients (or potential patients) is predicted for a given period of time, and a fixed amount of money is allocated to meet that demand (Tovian, 2004). In contrast to a fee-for-service system, the risk is shared between provider and payer, and offering more services does not generate more income for the provider. For example, in Germany, out-patient services by qualified psychologists are reimbursed from the same fund as other medical out-patient services (Schulte & Hahlweg, 2000). Insurance companies give a set amount of money to state-based regional provider associations on a quarterly basis, which in turn distribute the total available funds according to a ‘‘billing scoring system’’. The score for each individual provider is based on the number and type of services rendered to each patient, but the dollar value of the score varies as a function of the total amount of money available and the total number of services rendered by all providers over that period of time (Schulte & Hahlweg, 2000). Thus, cost containment strategies and capitation rein in uncontrolled escalation of overall health care costs by distributing less service to more people. From a public health perspective, this is desirable, but cost cutting must be balanced with optimal patient outcomes, because failure to adequately treat mental-health conditions impacts service utilization and costs in every area of primary and specialty health care (Gray et al., 2005). Competition for health care resources is therefore not so much an issue of who costs the least, but rather who adds value (Kiesler, 2000), where value is a function of optimal treatment outcomes achieved in a time-limited, resourceefficient manner for the greatest number of people. By virtue of their scientistpractitioner training, psychologists are particularly well prepared to function in such an empirically-based service system. The value of psychological services can be readily demonstrated via an information feedback loop between the data generated by routine outcome evaluation and the system managing health care costs (see Figure 13.1). The main difference to traditional outcome assessment is that psychologists must not only show that treatment works, but that it is cost-effective. Cost-effectiveness compares the costs of an intervention with the amount of improvement in health status (Kaplan & Groessl, 2002). Improvement is evaluated in relation to specified treatment goals and against standard criteria of normal functioning in a normative comparison group. Cost-offset compares the costs of an intervention with the costs saved elsewhere in the health care system as a result of that intervention, independent of the amount


Psychologists compete for health care resources

Figure 13.1. The scientist-practitioner approach to clinical practice is tailor-made for an empiricallybased health care system

of improvement in health status (Kaplan & Groessl, 2002). For example, a programme to achieve weight loss may reduce a patient’s number of visits to a hypertension clinic or eliminate the need for hypertension medication. If the reduction in visits and medication use saves more money than it costs to run the weight loss programme, a cost-offset has been achieved. There is robust evidence that psychological interventions can produce medical cost-offset effects, especially in the context of surgical procedures (Chiles et al., 1999). Although the demonstration of cost offset can enhance the value of psychological services, the goal of treatment is not to save money, but to improve health. Indeed, if health status is unaffected by treatment, the cost of that treatment amounts to waste of limited health care resources. For example, in the USA more than 650,000 arthroscopic surgeries for osteoarthritis of the knee are performed at a cost of over three billion dollars annually, but a recent carefully controlled trial showed that this intervention did not achieve any better pain relief or improvement in function than a placebo procedure (Moseley et al., 2002). This creates an opportunity cost problem (Kaplan & Groessl, 2002). The billions of


Psychologists as health care providers

dollars spent on ineffective surgeries for pain relief are not available to nonsurgical interventions that may have a superior evidence base (e.g., Gatchel, 2005). In the competition for health care resources, the onus is on psychologists to build on their strengths as scientist-practitioners and demonstrate that their treatments provide value for money, and that they add unique value as part of multidisciplinary health-care settings at the primary, secondary and tertiary levels of care (Tovian, 2004).

Psychologists add value to integrated care About three out of four mental-health patients are treated by primary care physicians (Hickie et al., 2005; Olfson et al., 2002), but evidence suggests that only a minority of patients receive adequate treatment at the primary level of care (Gray et al., 2005). For example, general practitioners fail to accurately recognize common mental disorders in 30 to 70 percent of patients who have a psychological problem (Coyne et al., 2002; Hickie et al., 2005; Sanchez & Turner, 2003), and they often fail to follow up or adjust treatment (Gray et al., 2005), or may even overprescribe psychotropic medications (Coyne et al., 2002). With the advent of new medications for depression such as selective serotonin re-uptake inhibitors (SSRIs), there has been a dramatic increase in the percentage of primary mental-health patients receiving medication, while the percentage of patients receiving psychological treatments declined (Gray et al., 2005). This is despite evidence that psychological treatments alone or combined treatments achieve superior treatment outcomes than pharmacotherapy alone, if one takes into account that psychological treatments are more effective at preventing relapse or recurrence of depression (Pettit et al., 2001). Thus, integrating mental health specialist services in primary care does not only add value by achieving better health outcomes, but integrated care is estimated to reduce health care costs by 20 to 30 percent (Gray et al., 2005). Importantly, when primary care physicians and mental health specialists operate as a team within the same setting, the number of referrals for psychological services that are followed through by the patient have been found to increase eightfold (Cummings, 1999). However, for psychologists to become valued players on integrated health care teams, they need to tailor their interventions and strategies to the needs and circumstances of general practice and hospital settings. As indicated in Figure 13.1, it is important in the initial encounters with patients to be problem-focused, so that assessment information is relevant to the specific referral question within the context of other assessment data contributed by different members of the multidisciplinary team (Haley et al., 1998).


Psychologists add value to integrated care

Likewise, treatment planning and implementation must be solution-focused, because in medical settings results are expected far more quickly than in traditional mental-health settings. Finally, the need to balance optimal care with efficient utilization of health care resources means that the modal form of treatment is guided by the concept of good enough treatment. As Kiesler (2000) noted, good enough treatment is guided by three principles: (a) no treatment is perfect, (b) more treatment might achieve better outcomes, but would do so at the expense of other patients who would miss out on care because the amount of available resources is finite, and (c) treatment to relieve acute distress and avoid relapse is sufficient under the circumstances. Moreover, not all patients need the same type and intensity of treatment. One way to ensure that patients receive all the care they need, but not more, is through the application of stepped care models. Davison (2000) described stepped care as ‘‘the practice of beginning one’s therapeutic efforts with the least expensive and least intrusive intervention possible and moving on to more expensive and/or more intrusive interventions only if deemed necessary in order to achieve a desired therapeutic goal’’ (p. 580). A stepped care approach is readily compatible with the purposeful planning, monitoring and modification of treatment strategies inherent in the scientistpractitioner approach to clinical practice (see Figure 13.1). The psychologist simply needs to increase attention to the concept of good enough treatment to maximize efficiency of resource allocation (Haaga, 2000). One example of how psychologists add value to integrated care by applying a focused set of treatment strategies within a stepped care framework is the treatment of hypertension. The first step in the sequential implementation of graded interventions involves the initiation of lifestyle modifications such as physical activity, weight loss, smoking cessation and stress management (Blumenthal et al., 2002). For instance, a weight loss of as little as 5 to 8 kilograms can produce clinically meaningful reductions in blood pressure (Blumenthal et al., 2002; Smith & Hopkins, 2003). If the lifestyle modifications fail to achieve blood pressure values within the desired range, adherence to the treatment regimen will be assessed, and care may be stepped-up by introducing a low dose of medications such as diuretics or beta-blockers. If response is still inadequate or side effects are experienced, another drug might be substituted or a second drug from a different class might be added. Thus, ongoing treatment decisions of stepping-up or stepping-down care are directly informed by the degree of satisfactory progress a patient makes. Psychological interventions add value because they can reduce or eliminate the need for medications in some patients, and they can improve poor rates of treatment adherence at every level or type of treatment modality (Blumenthal et al., 2002).


Psychologists as health care providers

Another example of how psychologists can add value to integrated care involves the stepped care approach to pain management. We mentioned earlier the poor outcomes of some very costly surgical procedures to alleviate knee pain (Moseley et al., 2002). In a stepped care approach, less costly and intrusive interventions should be attempted first. With respect to pain management, the first step is a brief, one-off psychological intervention addressing patients’ fears and beliefs about their pain to help them adjust to and manage their pain while returning to regular daily activities (Otis et al., 2005). For patients who do not improve after a few weeks, care can be stepped up to include multiple visits to providers from different disciplines (e.g., psychologists, physical therapists, physicians) to initiate structured activity programmes, practice cognitive-behavioural coping strategies, or prescribe pain medication to assist patients with resuming work and recreational involvement. Only if these less intense interventions fail to bring about improvement, or if the initial assessment indicates a high risk of becoming permanently disabled, Step 3 interventions should be considered. These may include surgical techniques and more intense specialty services often within multidisciplinary pain management centres (Gatchel, 2005; Otis et al., 2005). In sum, for psychologists to effectively bring to bear their unique knowledge and skills at the various levels of integrated care, their modal interventions must be focused, goal-oriented, resource-conscious and sufficiently effective to meaningfully improve patient functioning while minimizing the patient’s need for further or ongoing health care utilization. In addition, psychologists need to pay attention to the economics of health care and actively promote and market the value of their services (Tovian, 2004). The general scientist-practitioner training provides psychologists with a solid base from which to venture into this changing health care market. However, there are a number of specific, practical tips emerging from the nascent field of psychology as a health care profession on how psychologists need to adapt their repertoire of skills to provide quality services in primary care and other medical settings.

Psychologists need specific skills to adapt to integrated care settings 1.

Psychologists need to provide effective interventions expeditiously

Focus on the presenting problem or referral question. Clinical psychologists traditionally have been trained to conduct thorough assessments by obtaining information from lengthy interviews and extensive psychometric testing. In medical settings, psychologists must be able to assess presenting problems far more quickly and offer practical recommendations immediately (Gatchel &


Psychologists need specific skills to adapt to integrated care settings

Oordt, 2003). Rather than working within a standard 50-minute session schedule, initial appointments rarely exceed 25 to 30 minutes, with follow-up visits typically lasting between 15 to 20 minutes (Rowan & Runyan, 2005). Moreover, the initial appointment is not all reserved for assessment, but swiftly moves toward the initiation of an intervention. Rowan and Runyan (2005) recommend five phases for conducting a highly structured initial evaluation appointment: . Introduction (12 minutes). This is a well-rehearsed statement to clarify the psychologist’s role on the health care team, the purpose of the appointment, and the nature of information that will be documented in the patient’s medical record. A brochure with the same information may be handed to the patient at the same time for future reference. . Bridge to assessment (1030 seconds). The bridge usually is a sentence or two that serves to direct the patient’s attention straight to the referral question or primary presenting problem (e.g., ‘‘Dr. Morgan was concerned about your recent increase in your blood pressure and was wondering how your everyday behaviours and activities might contribute to it. What does a typical week look like for you in terms of physical activity, eating patterns, or daily stress?’’). A purposely vague bridge (e.g., ‘‘What brings you here today?’’) is less useful, because it is likely to invite responses that stray too much from the referral problem. . Assessment (1015 minutes). Assessment of the patient’s symptoms and daily functioning is focused on the referral question. To identify possible avenues for appropriate interventions, it is important to also assess strengths and strategies that have helped the patient in the past to alleviate or manage the impact of the presenting problem, as well as any barriers that might render particular psychological treatments less likely to succeed. . Bridge to intervention (12 minutes). This bridge is a brief summary of the most critical parts of the assessment information, how they link to the presenting problem, and what interventions have proven successful in treating this type of problem. Building on any helpful strategies the patient is already doing well can enhance rapport and readiness to engage in change. . Intervention (510 minutes). Intervention strategies should be concrete, practical and easy to implement after minimal instruction. They should be aimed at producing tangible symptom reduction or improvement in functioning soon after treatment commenced. Because opportunities for in-session education and demonstration of techniques are only brief, therapists have an extensive array of sufficiently detailed, stand-alone handouts and self-help materials ready for patients to take with them. They may also use behavioural prescription pads to outline the treatment plan and associated patient tasks.


Psychologists as health care providers

Follow-up appointments are variable in length and serve to help establish momentum for change. They can be as brief as 5 minutes if progress and current presentation of the patient reveal no need for more intense intervention or consultation. Be decisive with limited data. Sheridan & Radmacher (2003) noted that the great time pressures, the flood of information from multiple sources and people, and the distracting stimuli typical of medical environments may be stretching the health care provider’s capacity to process information accurately and efficiently. Hence, the ability to arrive at a correct diagnostic impression and intervention plan under those circumstances requires that psychologists adapt to the rapid pace of medical settings and learn to make efficient use of the brief time available with each patient (Gatchel & Oordt, 2003). Just as psychologists need to be comfortable with the principle of good enough treatment, they need to be tolerant of gaps in the data guiding their decisionmaking during case conceptualization and treatment planning. This process can be greatly facilitated by the judicious use of brief, validated psychometric instruments relevant to the particular aspects of a presenting problem (Gatchel & Oordt, 2003). Fill your toolbox with effective short-term treatments. Considering the practicalities of integrated care settings, the modal form of treatment will be solutionfocused and brief (Kiesler, 2000; Sanchez & Turner, 2003). Hence, students should strive to develop an extensive repertoire of behavioural and cognitivebehavioural short-term strategies. Become an expert in motivational interviewing techniques. Medical patients are often reluctant to engage in action-oriented lifestyle changes (Gatchel & Oordt, 2003). Brief motivational interventions can enhance a patient’s readiness to make the recommended changes and become an active partner in their own treatment. As with other interventions in medical settings, the constraints on time and the limited number of patient contacts requires that motivational interviewing is adapted to a briefer format, sometimes referred to as brief negotiation (Resnicow et al., 2002). Whether it is the adoption of lifestyle changes or adherence to medication regimens, treatment compliance is a common problem. Sheridan and Radmacher (2003) list the following principles for encouraging treatment compliance: . Interact with patients in a warm, empathic manner. . View patients as a key partner in the treatment team. . Be specific with your instructions and make sure they are understood. . Explain why you are confident that the treatment plan will be effective. . Provide skills training when appropriate. . Arrange for social support when appropriate.


Psychologists need specific skills to adapt to integrated care settings

. . . . 2.

Provide praise for effort and for actual compliance. Use at-home reminders. Anticipate barriers to compliance and help patients cope with them. Monitor compliance in a caring, respectful manner.

Psychologists need to be good team players

Accept all referrals. Psychologists in medical settings are expected to attend to all behavioural and psychosocial aspects of general health care (Gatchel & Oordt, 2003). To the extent that they are willing and able to meet those expectations, they will be regarded as a valuable asset to the team. In fact, psychologists should not just wait for patients to come to them, but they should actively promote their services and enhance the visibility of the broad range of interventions they offer (Haley et al., 1998). Communicate clearly and frequently. Referring physicians and other medical staff are the psychologist’s primary customers. Psychologists must make sure that their interventions are in sync with the treatment objectives of other members in the team. According to Gatchel and Oordt (2003), good communication with medical colleagues involves (a) getting to the point quickly, (b) avoiding psychological lingo and jargon, (c) keeping documentation succinct, (d) giving feedback promptly, and (e) expressing one’s perspective confidently, but not be offended if one’s advice is not taken on board by other team members. It is also important to avoid ambiguity when responding to requests for input and always clarify what the specific referral question is (Haley et al., 1998). Be sensitive to and tolerant of hierarchical team structures. Physicians typically have the final say in treatment matters. Medical appointments often take precedence over non-medical (even scheduled) activities. For example, patients participating in a small group session on stress management may be pulled out for medical tests without prior notice. Be flexible and available. Psychologists need to establish ways of being reachable when not in the office and should be willing to respond to calls for assistance without delay whenever possible. This might also mean interrupting the sanctity of the treatment session, which psychologists are accustomed to when working in traditional mental-health clinics (Gatchel & Oordt, 2003). 3.

Psychologists need to gain familiarity with all things medical

Become knowledgeable about physical conditions, medical procedures and medications. When working on psychological components of a patient’s treatment plan, it is essential that psychologists remain mindful of the patient’s experience with physical disability and suffering (Haley et al., 1998). They should develop a basic understanding of the symptoms associated with common health problems


Psychologists as health care providers

and the procedures and medications to treat them (Gatchel & Oordt, 2003). Because patients presenting with psychological symptoms in integrated care settings may first be assessed by a psychologist, it is important that psychologists are able to obtain a brief medical history (Robinson & James, 2005). This is important because psychological symptoms can mask the presence of certain medical disorders. A brief set of questions can be incorporated into the interview asking about recent changes in health status, awareness of any medical conditions, family history of medical disorders, current medications, results of last physical examination, history of head trauma of loss of consciousness, and changes in weight, diet, sleep or appetite (Robinson & James, 2005). Become familiar with medical reimbursement codes. Recently, progress has been made in the US toward establishing reimbursement codes for psychological services that do not require a mental health diagnosis but target physical health problems (Smith, 2002). Similarly, in Australia, psychologists are now eligible to receive Medicare rebates for their services (Martin, 2004). These were significant milestones toward redefining ‘‘health as a multidisciplinary enterprise rather than a medical monopoly’’ (Martin, 2004, p. 5). Psychologists need to keep abreast of further developments in this arena, as these are likely to further smooth the path for psychologists practicing in medical settings. When in the medical world, do as the medicos do. Psychologists are the new kids on the medical block. Becoming part of the team means that psychologists, while maintaining their distinctive qualities, must adopt the pace and culture of their medical colleagues. This includes getting involved in the things that the other providers do, such as attending presentations by pharmaceutical representatives, staying informed about current medical issues by reading relevant medical journals, and participating in professional events and social functions (Gatchel & Oordt, 2003). Psychologists should also be willing to be trained and educated on issues that initially go beyond their expertise (Haley et al., 1998). Admitting ignorance is the first step toward acquiring the information necessary to become familiar with the local culture. Receptiveness to the complimentary expertise offered by psychologists is highest if it comes packaged in the wrappings and trimmings familiar to medical professionals. This is not to imply that psychologists should disguise their professional identity or not stand behind their perspective in the face of opposing opinions (Gatchel & Oordt, 2003). After all, it is their different training and expertise that adds value to the medical model of health care delivery. 4.

Psychologists need to be accountable for outcomes

Accountability requires good skills in database management. Kiesler (2000) noted that ‘‘the database needed to track services is about the same as the


Psychologists need specific skills to adapt to integrated care settings

database needed to do good research’’ (p. 486). Thus, psychologists with a scientist-practitioner background are well equipped to enhance the quality and utility of locally relevant data management systems. However, research-skilled psychologists must fine-tune their approach to documenting outcomes in line with the principles of time-efficiency, practical utility and good enough treatment.


Psychologists need to attend to ethical issues

Adapting the delivery of psychological services to the pace and culture of medical settings raises some important ethical issues for psychologists. Perhaps foremost among those is the ethical obligation to provide services only within the boundaries of one’s competence. In particular, the pressure to conduct consultations more rapidly and for a larger number of patients than is typical of the specialist mental-health setting must be balanced with a calm and methodical approach to determining if more comprehensive psychological assessments and/or interventions are indicated (e.g., in cases of high suicide risk, substance abuse, or complex family problems). If so, psychologists must triage those patients and refer them to appropriate specialist care (Haley et al., 1998). In this context, it is important that psychologists guard their professional integrity and are up-front with a patient about their particular role in the patient’s overall care, so that they avoid making unwise commitments or raising false expectations (Gatchel & Oordt, 2003). Finally, confidentiality is an issue of heightened concern in settings where many staff members from different disciplines are involved in patient care and may have access to patient records. Although obtaining consent from each patient for allowing communication between relevant team members about the patient’s care is essential, the psychologist should divulge only patient information that is pertinent to other colleagues, and be judicious about what is necessary to document in the medical record (Gatchel & Oordt, 2003).


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Useful resources

The preceding chapters have been organized around a model of science-informed practice. This begins with the distillation of client data through filters of experience and documented evidence, into an assessment and formulation. A treatment plan is formulated along with a programme of evaluation. Therefore, useful resources have been organized according to these same principles.

Collecting client data Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford. (Esp. chapters 35). Egan, G. (2002). The skilled helper: A problem management and opportunity development approach to helping. Pacific Grove, CA: Brooks/Cole. Miller, W. R., & Rollnick, S. (Eds.). (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY: Guilford Press. Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York, NY: Oxford University Press.

Using the empirical and theoretical literature Scho¨n, D. A. (1983). The reflective practitioner: Toward a new design for teaching and learning in the professions. San Francisco, CA: Jossey-Bass. Stricker, G., & Trierweiler, S. J. (1995). The local clinical scientist: A bridge between science and practice. American Psychologist, 50, 9951002. Thorne, F. C. (1947). The clinical method in science. American Psychologist, 2, 161166. Trierweiler, S. J., & Stricker, G. (1998). The scientific practice of professional psychology. New York, NY: Plenum Press. Woody, S. R., Detweiler-Bedell, J., Teachman, B. A., & O’Hearn, T. (2003). Treatment planning in psychotherapy: Taking the guesswork out of clinical care. New York, NY: Guilford.


Useful resources

Accessing clinical experience Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision (3rd Ed.). Boston, MA: Pearson. Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association. Stamm, B. H. (Ed.) (2003). Rural behavioral health care: An interdisciplinary guide. Washington, DC: American Psychological Association. Watkins, C. E. (Ed.) (1997). Handbook of psychotherapy supervision. New York, NY: Wiley.

Assessment and case formulation Antony, M. M., & Barlow, D. H. (Eds.). (2002). Handbook of assessment and treatment planning for psychological disorders. New York, NY: Guilford. Fischer, R. D., & Corcoran, K. (Eds.). (1994). Measures for clinical practice: A sourcebook: Vol. 1. Couples, families, and children (2nd Ed.). New York, NY: The Free Press. Fischer, R. D., & Corcoran, K. (Eds.). (1994). Measures for clinical practice: A sourcebook: Vol. 2. Adults (2nd Ed.). New York, NY: The Free Press. Groth-Marnat, G. (2003). Handbook of psychological assessment. New York, NY: Wiley. Hayes, S. C., Barlow, D. H., & Nelson-Gray, R. O. (1999). The scientist-practitioner: Research and accountability in the age of managed care (2nd Ed.). Boston, MA: Allyn & Bacon. Hersen, M., & Turner, S. M. (2003). Diagnostic interviewing (3rd ed.). New York, NY: Kluwer Academic/Plenum. Maruish, M. E. (Ed.) (1999). The use of psychological testing for treatment planning and outcomes assessment. Mahwah, NJ: Lawrence Erlbaum. Meyer, R. G. (2003). Case studies in abnormal behaviour (6th Ed.). Boston, MA: Allyn & Bacon. Oltmans, T. F., Neale, J. M., & Davison, G. C. (2003). Case studies in abnormal psychology (6th Ed.). New York, NY: Wiley. Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. New York, NY: Norton. Rogers, R. (2001). Handbook of diagnostic and structured interviewing. New York, NY: Guilford. Sattler, D. N., Shabatay, V., & Kramer, G. P. (1998). Abnormal psychology in context: Voices and perspectives. New York, NY: Houghton Mifflin. Sattler, J. E. (2001). Assessment of children: Cognitive applications (4th Ed.). La Mesa, CA: Jerome M. Sattler, Publisher, Inc. Sattler, J. E. (2002). Assessment of children: Behavioral and clinical applications (4th Ed.). La Mesa, CA: Jerome M. Sattler, Publisher, Inc. Spitzer, R. L., Gibbon, M., Skodol, A. E., Williams, J. B. W., & First M. B. (2001). DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: APA Press. Woody, S. R., Detweiler-Bedell, J., Teachman, B. A., & O’Hearn, T. (2003). Treatment planning in psychotherapy: Taking the guesswork out of clinical care. New York, NY: Guilford.


Useful resources

Treatment planning and delivery Antony, M. M., & Barlow, D. H. (2002). Handbook of assessment and treatment planning for psychological disorders. New York, NY: Guilford. Barlow, D. H. (1993). Handbook of psychological disorders (3rd Ed.). New York, NY: Guilford. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York, NY: Guilford. Burns, D. (1999). The feeling good handbook. New York, NY: Plume. Greenberger, D., & Padesky, C. A. (1995). Mind over mood: A cognitive therapy treatment manual for clients. New York, NY: Guilford. Hawton, K., Salkovskis, P. M., Kirk, J., & Clark, D. M. (1988). Cognitive behavior therapy for psychiatric problems: A practical guide. Oxford, UK: Oxford Medical Publications. (A reliable website for information on medical conditions, procedures, and medications). James, L. C., & Folen, R. A. (Eds.) (2005). The primary care consultant: The next frontier for psychologists in hospitals and clinics. Washington, DC: American Psychological Association. Kanfer, F. H., & Goldstein, A. P. (1991). Helping people change: A textbook of methods (4th Ed.). New York, NY: Pergamon. Kaplan, H. I., & Sadock, B. J. (Eds.) (1993). Comprehensive group Psychotherapy (3rd Ed.). Baltimore, MD: Williams & Wilkins. Ledley, D. R., Marx, B. P., & Heimberg, R. G. (2005). Making cognitive-behavioral therapy work. Clinical process for new practitioners. New York, NY: Guilford. Martin, G., & Pear, J. (1988). Behavior modification: what it is and how to do it. New York, NY: Prentice Hall. Masters, J. C., Burish, T. G., Hollon, S. D., & Rimm, D. C. (1987). Behavior therapy: Techniques and empirical findings (3rd Ed.). New York, NY: Harcourt Brace Jovanivich. Maruish, M. E. (2003). Essentials of treatment planning. New York: Wiley. Padesky, C. A., & Greenberger, D. (1995). Clinician’s guide to mind over mood. New York, NY: Guilford. Schein, L. A., Bernard, H. S., Spitz, H. I., & Muskin, P. R. (Eds.) (2003). Psychosocial treatment for medical conditions: Principles and techniques. New York, NY: Brunner-Routledge. Traverse, J., & Dryden, W. (1995). Rational emotive therapy: A client’s guide. London, UK: Whurr. Van Hasselt, V. B., & Hersen, M. (1996). Sourcebook of psychological treatment manuals for adult disorders. New York, NY: Plenum Press. Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th Ed.). New York, NY: Basic Books.

Measurement, monitoring, evaluation and accountability Carey, R. G. (2003). Improving healthcare with control charts: Basic and advanced SPC methods and case studies. Milwaukee, WC: Quality Press.


Useful resources Hayes, S. C., Barlow, D. H., & Nelson-Gray, R. O. (1999). The scientist-practitioner: Research and accountability in the age of managed care (2nd Ed.). Boston, MA: Allyn & Bacon. Maruish, M. E. (Ed.) (2004). The use of psychological testing for treatment planning and outcomes assessment: General considerations (Vol. 1) (3rd Ed.). Mahwah, NJ: Lawrence Erlbaum. Maruish, M. E. (Ed.) (2004). The use of psychological testing for treatment planning and outcomes assessment: Instruments for Children and Adolescents (Vol. 2) (3rd Ed.). Mahwah, NJ: Lawrence Erlbaum. Ogles, B. M., Lambert, M. J., & Fields, S. A. (2002). Essentials of outcome assessment. New York, NY: Wiley. Woody, S. R., Detweiler-Bedell, J., Teachman, B. A., & O’Hearn, T. (2003). Treatment planning in psychotherapy: Taking the guesswork out of clinical care. New York, NY: Guilford.


ABC model 112 accountability 2, 24, 47, 134, 149, 158, 189 assessing clients 27, 28 additional assessment and testing 56–9 client focused research approach 59 COMPASS tracking system 58 monitoring, empirical evidence 58 phases to therapy, Lutz et al. 58 pre-treatment scores, client 59 assessment process 27 current diagnostic practices 29 diagnostic manuals 27 initial interview, annotated proforma 40 mental disorder 28 attrition rates 137 behavioural case formulation, functional analysis 61–7 aim 62 antecedents, categories 62 mediators 62 moderators 62 case example 66–7 causal variables 62 clinical experimentation 66 components 62, 64 antecedents 62 behavior 63 consequences 63 consequences, categories 63–4 negative reinforcer 64 positive reinforcer 63 punisher 63 response cost 64 definition 62

functional analysis, components 63 hypothesis-driven approach 61 limitation 67 target behavior, focus 62 behavioural function identification, 65 assessment methods 65 analog 65 indirect 65 naturalistic 65 behaviour therapy, psychotherapy 95–109 case formulation, assessment and treatment linkage 60, 91 client information, importance 60 definition, Eells 60 process 61 reasons for behaviour, variables 65 automatic reinforcement 65 negative reinforcement 65 positive reinforcement 65 steps 61 case management 157–80 confidentiality, maintenance 160–6 confidentiality negotiation, working with minors 162–3 confidentiality to patients 161–2 disclosure scope, control 163–4 information disclosure guidelines 162–3 patient information, securing 164–6 emergency procedures 173–4 core principles 173 evaluation and treatment phase, tasks 178–80 termination/transfer report 179



case management (cont.) good record maintenance 157–60 characteristics, good clinical record 159–60 clinical activity documentation, purpose 157–9 intake and treatment planning phase, tasks 166–74 case information, presentation and documentation 167–9 ethical issues 167 informed consent 166 referral issues, clarification 167 risk assessment and management 169–74 progress notes, writing 176–7 tasks 157 treatment implementation phase, tasks 174–8 progress toward goal attainment, documentation 174 termination planning, initiation 175–8 case presentation components, importance 168 Clark, cognitive model of panic attack 77 client data, conceptualization/ documentation/management 158 clients, relating with 11, 15–20 body language 17 closed/open questions 16, 18–19 degree of influence, clinician 19 eye-contact, importance 16–17 introduction of problems, client 16 preliminary introduction, therapist 15 therapist responses, potentially useful 19 therapy, goal of 19 troubleshooting, common client issues 23–6 agitated clients 24 anxious clients 24 interview refocusing 25 personal information enquiry, by client 25 session, collaborative nature of 25

support and sympathy, expression 24 talkative clients 24 therapist, attitude 23 voice tone 17–18 clinical psychology practice, stake holders 6–10, 147, 183 effectiveness research 7 efficacy studies 6 health care industrialization 9 managed (health) care organizations, evolution 9 presenting evidence 8–9 research activity types 6 society, interests of 7 stakeholders, three classes 6 subjective units of discomfort (SUD) 8 cognitive behavioural case formulation 67–80 case example 69–80 formulation and treatment, link 79 perpetuating cognitions and consequences 73–5 potential problems 80 precipitating variables 71–3 predisposing factors 75–6 prescribed interventions 79–80 problems, presentation of 69–71 provisional conceptualization 76–9 case formulation model 69 case formulation worksheet 70 completed worksheet 80, 81 clinical practice model, inclusion 82 personality inventory 78 NEO-PI-R 78 SCL-90-R 78 Persons model 67 core beliefs 67 hypothesis, working 68 origins 68 precipitants and activating situations 68 problem list 67 strengths 69 treatment plan 68



treatment, predicted obstacles 68–9 weaknesses 69 cognitive therapy, psychotherapy 111–17 Acceptance and Commitment Therapy (ACT) 117 cognitive (behavior) therapy, Beck 112 bias, types 112–13 automatic thoughts 113 cognitive restructuring 111 downward technique, Burns 113–14 rationale 114–17 rational emotive therapy (RET), Ellis 111–12 procedural steps 112 unconscious thoughts, role 114 confidentiality 15, 24, 157, 244 contigency management 96–104 behavioural maintenance 103–4 conditioned excitors 104 conditioned inhibitors 104 occasion setters 104 contingency contracting 101 desired behaviors, increasing 97 negative reinforcement 97 positive reinforcement/reward 97 pyramid chart 97 social reinforcement 97 differential reinforcement types 100 habit reversal 101 treatment components 101 new behaviour introduction, strategies 102–3 chaining, types 103 shaping and reward successive approximations 102–3 performance variables 101–2 reinforcement schedules 102 response 102 subject 101–2 problem behaviours, decreasing 98–100 clinical practice, phenomena 99 contingent punishment 98 over correction 100 positive practice 100 response cost and extinction 99 satiation 99

time-out reinforcement 98–9 reinforcer, definitions 96–7 reinforcers, types 97 cost-containment 4 diagnostic and statistical manual of mental disorders (DSM) 29–33 Axis I, clinical disorders 30–1 Axis II, personality disorders and mental retardation 31 Axis III, general medical conditions 31 Axis IV, psychosocial and environmental problems 97 Axis V, global assessment of functioning (GAF) 32–3 DSM-IV 29–33 diagnostic interview 34–9 generalized anxiety disorder (GAD), client with 35–6 client, complete picture of 38 clinician, choice of direction 37 ‘concentration’, meaning of 36 coping resources identification 39 diagnostic aspect 38 DSM-IV criteria 36–7 problem history 37 proforma, for assistance 39 series of stages, Prochaska et al. 39 diagnostic interview, different client groups 39–48 Beck depression inventory (BDI) 42 behaviour and symptom identification index (BASIS-32) 42 Center for epidemiological studies  depression scale 42 general health questionnaire (GHQ) 42 Hamilton anxiety scale (HAS) and the Hamilton rating scale for depression (HAM-D) 42 interviewing children 39 interviewing elderly groups 41 psychological symptoms, screening for 41–3 SCL-90-R & BSI 41



diagnosis limitations and future directions 54–6 identifiable psychometric assessments 55 observable symptoms, focus on 55 prevention and early intervention, focus on 55 specific criteria introduction 55 treatment outcome, limited predictors 55 unlisted problems, clinical disorders 55 diagnostic systems 29–34 cultural sensitivity 34 dialectical behavior therapy (DBT), psychotherapy 109–11 dilemmas 110 drawback 111 merits 111 documentation tasks 157 dual relationship 197, 228, 232 empathy 12, 60, 105, 207 empirical foundations, therapeutic relationship 11–14 process variables, categories 14 review on therapy-specific behavior, Orlinsky et al. 13 studies, Miller et al. 12–3 therapeutic process variables and outcome, relationship size 13, 21 empirically supported treatments (ESTs) 11, 12 delivery 120–32 exposure to feared stimuli, example 120–5 essential targets for change, Barlow 121 exposure treatment, aim 122 self-efficacy theory 121 new treatments 133 rationale for exposure, example 123–5 relaxation, example 125–32 exposure 94 Eysenck, criticisms 1–2

functional analysis 61 group treatment 134 assessment and pre-group orientation 137–41 best participation, guidelines 139 clarity format and program duration 139 faith and optimism 140 frustrations and disappointments, anticipation 140 group formulation 138 individual case formulation 137 patient enlistment 139 preparatory tasks 139–41 setting ground rules 140 typical practice adaptations 141 group, patient selection for 137 group, start activities 141–2 first session, importance 141–2 rationale of program, review 142 interpersonal interaction, therapeutic tool 134 progress and outcomes, monitoring and evaluation 142–6 easy-to-follow feedback 144 group progress data, routine examination 144 individual case formulation and treatment, integration 136, 144 program evaluation 146 successful outcomes, accurate documentations 146 systematic accounting, group progress 145 smoking cessation treatment 136 biological markers, carbon monoxide 136 change trajectories 143 example 138–9, 142–4 patient characteristics, general information 138 Tobacco Dependence Treatment Handbook 135 treatment progress, pattern of 144, 145



treatment program selection 135–7 treatment strategies, practice guidelines for 135 health care providers, psychologists as 240 effective interventions, providing 246–9 presenting problems, focus on 246 limited data, decisiveness 248 effective short-term techniques 248 motivational interviewing techniques 248 ethical issues, attending 251 good team players, psychologists as 249 accepting referrals 249 clear and frequent communication 249 sensitive and hierarchical team structures 249 flexibility and availability 249 health care resources, psychologist competition 241–4 evidence-based treatments 241 cost-effective care delivery 241 fee-for-service model 241 billing scoring system 242 cost-effectiveness 242 cost-offset 242 illness, leading causes 240 initial evaluation phases, Rowan and Runyan 247–8 integrated care, value addition 244–6 selective serotonin reuptake inhibitors (SSRIs) 244 problem-focussed initial encounter 244 solution-focused treatment planning 245 good enough treatment, guiding principles for 245 integrated care settings, skillsets 246–51 medical things, familiarity with 249–50

physical conditions and medications, knowledge on 249 medical reimbursement codes, familiarity with 250 medicos, adopt with 250 out comes, accountability 250 psychological services, necessary/ discretionary health care 241 stepped care models, Davidson’s definition 245 stepped-up approach, treatment of hypertension 245 stepped care approach, pain management 246 homework 199 humanity of clients, cross-cultural and ethical aspects 217 assessing ethical dilemmas, 227 clinical psychology practice, factors affecting 217–19 health intervention 217 Schou and Wight, studies on dental heath campaign 218 confidentiality 227–8 legal rules and ethical standards 228 culture sensitive practice, clinical psychology 219–22 caveats 219 individualism 220 dual relationships 228–9 Canadian Psychological Association 229 sexual relationships 229 ethical decision-making, guidelines 225–7 British Psychological Society, 226 Canadian code of ethics for psychologists 225 Canadian Psychological Society 226 Kluckhohm and Stodtbeck, culture-sensitive practice parameters 220–2 activity, preferred mode 221 behavioural changes 222 human character 220



humanity of clients, cross-cultural and ethical aspects (cont.) Kluckhohm and Stodtbeck, culture-sensitive practice parameters (cont.) people and natural world, relationship 220 people relationships 221 relational orientation 220 self-evaluation 221 time orientation 221 structured problem solving, steps 222–4 ethical decision-making 224–9 interpersonal psychotherapy (IPT) basics 117–20 developmental stages 118 interpersonal deficits 119–20 interpersonal role disputes 118–19 role transitions 119 case example 80–90 depression, deal with 82–6 interpersonal problems, assessment 86–8 therapeutic contract, negotiation 89–90 case formulation 80–92 CBT, contrast with 90–2 interpersonal communication 86 loss and growth 86 phases 81 international classification of diseases (ICD) 29 depressive episode, varieties 33 disorders, categories 33 ICD-10 33–4 management tasks 157 mental disorders 28, 85, 237 mental status examination (MSE) 48–54 Cognitive Capacity Screening Examination (CCSE) 54 cognitive state 50–4 attention and concentration 51 delusions 52

derealization/depersonalization 53 hallucinations 52 insight and judgement 53 intelligence and abstraction 54 memory 51 orientation 50 perception 52 speech and language 53 thought disturbances 51 thought, form and content 51 emotional state 50 mood and affect 50 High Sensitivity Cognitive Screen (HSCS) 54 Mental Status Questionnaire (MSQ) 54 mini mental state exam 54 physical state 49–50 appearance 49 attitude 49 behaviour 49 motor activity 49 Short Portable Mental Status Questionnaire (SPMSQ) 54 Treatment Protocol Project 48, 54 monitoring 7, 56, 101, 137, 158, 182 motivation 68, 101, 136, 206 motivational interviewing 144, 207, 248 patient information, securing 164–6 guidelines, risk avoidance 164–5 problem solving 219 programme evaluation 147, 148 change, advocating and promoting 155–6 empirically based outcome evaluation 156 key findings communication, opportunities 155 recommendations, non-use and translation 155 recommended changes, adoption 156 strategies, promotion 155 team formation 156 conclusions 147 evaluation data 147



evaluation findings, data collection and analysis 152–3 evaluation findings, translation 153–5 good recommendations, qualities 153, 154 written recommendations 154 evaluation plan, development 151–2 considerations, issues 151 cost estimation, plan 152 data collection and management strategies, selection 151–2 dissemination strategies, outcomes of the evaluation 152 information, recipients and users 151 personnel and material resources 151 five basic steps 149–56 negotiation and communication skills 147, 148 right questions, asking 149–51 clarificative evaluation 149 impact evaluation 150 interactive evaluation 150 monitoring evaluation 150 outcome monitoring data 150 proactive evaluation 149 skill training, modes 148 punishment 64, 97

addressing client needs 234 consultation seeking 235 educating client 234 monitoring comfort level 234 obtaining informed consent 234 out-of-therapy discussion 233 overlapping relationship, termination 235 overlapping relationships documentation, case notes 233 procedure development 234 role compartmentalization, 233 role-boundary conflicts, monitoring 235 slippery slope phenomenon 235 time limits 234 worst case scenario, imagination 234 professional isolation, coping strategies 235–9 rural mental health services, drawbacks 230–1 fishbowl situation 231 help-seeking situation 231 rural practice, scientist practitioner approach 232 rural practitioners, public image 231 telehealth 236 definition 236

questions 16, 36, 96, 148 reinforcement 65, 96 relaxation 97, 101 Rescorla-Wagner model 99 resistance 199 rural and remote settings, working in 230 fishbowl, professional boundaries maintenance 231–5 multidisciplinary care, natural support networks and 236–9 clinical activities 238 community education 237 community referral systems 238 generalist role 238 partnership development 237 multiple relationship management, strategies 233

science-informed model of clinical psychology practice, approach 1, 4–5, 147, 152, 182 clienttherapist relationship 4 clinical practice, public accountability 5 outputs 10 professional organizations, promotion by 9 treatment data/client decisions linking, case formulation 4 treatment selection 94 scientistpractitioner model, approach 2–3, 243 Lightner Witmer 2 screening 41 self-management, contingency management 104–9



behavioral contracting, use 105–7 modeling 107–9 applications 108 imitation 107 observational learning 107 role-plays 109 role-reversal 109 types 108 motivational interviewing strategy 105 role, reasons 104 structured and semi-structured diagnostic interviews, adults 43–6 anxiety disorders interview schedule for DSM-IV (ADIS-IV) 44 composite international diagnostic schedule (CIDI) 44 diagnostic interview schedule (DIS) 44 instruments available 43–6 mini-international neuropsychiatric interview (MIDI) 45 primary care evaluation of mental disorders (PRIME-MD) 45 schedule for affective disorders and schizophrenia (SADS) 45 SADS lifetime anxiety for DSM-IV 45 schedule for clinical assessment in neuropsychiatry (SCAN) 46 structured clinical interview for DSM-IV axis-I disorders (SCID) 46 SCID-CV, SCID-I 46 symptom-driven diagnostic system for primary care (SDDS-PC) 45 structured and semi-structured diagnostic interviews, children 46–7 child and adolescent psychiatric assessment (CAPA) 46 child assessment schedule (CAS) 47 children’s interview for psychiatric syndromes (ChIPS) 47 diagnostic interview schedule for children (DISC) 46 interview schedule for children and adolescents (ISCA) 47

schedule for affective disorders and schizophrenia for school-age children (K-SADS) 47 structured and semi-structured diagnostic interviews, older adults 47 Cambridge mental disorders of the elderly examination (CAMDEX) 47 comprehensive assessment and referral evaluation (CARE) 47 Geriatric mental state schedule (GSM) 47 suicide risk level determination 169–70 categories 172–3 decision framework, Joiner et al. 169–71 management strategies 170, 172–3 supervision 181 agenda setting 188–9 audio- and video tapes, learning from 189–91 impression management, guarding against 191 stage setting 190 tape segments selection 190 challenge to advance 194 competency-based approach, types 184–6 cognitive-behavioral supervision 184 development approaches 185 Gestalt supervision 184 process-based approaches 185–6 formative and summative evaluation 194–5 goals 181–4 quality assurance 183 supervision data presentation 184 group supervision 193 impression management checklist 191 learning supervisory skills 195–8 prescriptive strategies 197–8 reflective strategies 196–7 supportive strategies 196 reflective supervisee, 186–8



client, follow-up session 188 client, subsequent session 188 preparatory events, prior to supervision 187 solutions generated, during supervision 187 subsequent supervision 187–8 trigger event 186 trigger event, reactions to 186 supervisory activities and outcomes, accounting for 191–3 supervision record form 192 supervisory practice, pros and cons 181 tension identification chart 128 termination planning 177, 206 therapeutic alliance, building 14–23 client communication, strategies 20–1 empathic understanding 22 encouraging 20–1 paraphrasing, keyskills 21 summary creation 21 components 14–15 therapy session conduct, conclusions 15 treating clients 93 psychotherapy literature 93 limitations 94 types 93 psychotherapy, types 95

treatment manuals 11, 135 treatment non-compliance, managing 199 clienttherapist interactions, examples 199, 208, 209, 211, 212 homework non-compliance, managing 214–16 motivation enhancement, resistance management 206–14 avoiding argumentation 210–1 developing discrepancies 209–10 empathic communication 207–9 general principles, motivational interviewing 207 Miller and Rollnick, contributions 207 resistance, rolling with 211–2 self-efficacy, supporting 212–14 therapeutic resistance 212 resistance and non-compliance, model of 199–201 resistance management, at different phases 202–6 ‘‘search and destroy’’ approach 206 assessment phase 202–3 examples 204–5 implementation phase 203–5 termination phase 205–6 therapeutic resistance 201–2 transtheoretical approach 202 Wachtel, definition 201